Provider Demographics
NPI:1639140197
Name:REYNOLDS, JESSE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
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:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVE
Mailing Address - City:JOINT BASE LEWIS-MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431
Mailing Address - Country:US
Mailing Address - Phone:912-368-3375
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 JACKSON, AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-967-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA60698388OtherPA LICENSE