Provider Demographics
NPI:1508808577
Name:REYNOLDS, JEFFREY A (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 PEERLESS XING NW STE 200
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3785
Mailing Address - Country:US
Mailing Address - Phone:423-479-4165
Mailing Address - Fax:
Practice Address - Street 1:908 W 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3894
Practice Address - Country:US
Practice Address - Phone:423-586-4231
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4050526OtherBCBS
TN4050526OtherBCBS
TNP00818Medicare UPIN