Provider Demographics
NPI:1558858571
Name:REID, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:REID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 E BROAD ST APT 606
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1726
Mailing Address - Country:US
Mailing Address - Phone:907-738-3107
Mailing Address - Fax:
Practice Address - Street 1:280 E BROAD ST APT 606
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1726
Practice Address - Country:US
Practice Address - Phone:907-738-3107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY740587163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse