Provider Demographics
NPI:1578181780
Name:REID, JACQUELINE YVETTE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:YVETTE
Last Name:REID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 CENTRAL AVE APT T1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5953
Mailing Address - Country:US
Mailing Address - Phone:901-438-3900
Mailing Address - Fax:
Practice Address - Street 1:2924 WALNUT GROVE RD STE 4
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2719
Practice Address - Country:US
Practice Address - Phone:901-209-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health