Provider Demographics
NPI:1134569346
Name:REITER, JESSICA EVE (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:EVE
Last Name:REITER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:EVE
Other - Last Name:KUNKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1450 S CANFIELD NILES RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4085
Mailing Address - Country:US
Mailing Address - Phone:330-799-8752
Mailing Address - Fax:330-799-8754
Practice Address - Street 1:1450 S CANFIELD NILES RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4085
Practice Address - Country:US
Practice Address - Phone:330-799-8752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH475531Medicare PIN