Provider Demographics
NPI:1922348812
Name:REYES, JERSEY-ROY
Entity Type:Individual
Prefix:MR
First Name:JERSEY-ROY
Middle Name:
Last Name:REYES
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 1:14563 GOLDEN OAK RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2261
Mailing Address - Country:US
Mailing Address - Phone:202-413-5984
Mailing Address - Fax:
Practice Address - Street 1:4320 FOREST HILL DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5766
Practice Address - Country:US
Practice Address - Phone:703-667-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603473225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant