Provider Demographics
NPI:1740882315
Name:REAVES, JERRY A (CERT HAIR LOSS SPC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:REAVES
Suffix:
Gender:M
Credentials:CERT HAIR LOSS SPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46227 TIMBERMINE LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4131
Mailing Address - Country:US
Mailing Address - Phone:609-608-8086
Mailing Address - Fax:
Practice Address - Street 1:46227 TIMBERMINE LN
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4131
Practice Address - Country:US
Practice Address - Phone:609-608-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management