Provider Demographics
NPI:1689825812
Name:REILLY, JAMIE LEE (AUD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:LEE
Last Name:REILLY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LEE
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1638 OWEN DR
Mailing Address - Street 2:ATTN: SPEECH/AUDIOLOGY DEPT.
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-4060
Mailing Address - Fax:910-615-5480
Practice Address - Street 1:1839 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-323-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8281237600000X
237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2696764OtherMEDICARE PTAN
NC2696764Medicare PIN