Provider Demographics
NPI:1205105731
Name:REYNOLDS, JESSICA (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:CLINIC TOWER, 7TH FLOOR A7D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:619-543-6164
Mailing Address - Fax:
Practice Address - Street 1:631 PROFESSIONAL DR STE 300
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3371
Practice Address - Country:US
Practice Address - Phone:770-962-9977
Practice Address - Fax:770-339-9804
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119307208600000X
GA85849208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery