Provider Demographics
NPI:1700280781
Name:REYER, JESSE (PROSTHETIST)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:REYER
Suffix:
Gender:M
Credentials:PROSTHETIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5526 SCOTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BENTONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39040-9310
Mailing Address - Country:US
Mailing Address - Phone:601-941-3238
Mailing Address - Fax:
Practice Address - Street 1:1403 PLAZA DR
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2719
Practice Address - Country:US
Practice Address - Phone:662-746-8331
Practice Address - Fax:662-673-0043
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
7176150001Medicare NSC