Basic Information
| Provider Information | |||||||||
| NPI: | 1053705764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVES | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22727 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392252727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004644 | ||||||||
| FaxNumber: | 6012004645 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004644 | ||||||||
| FaxNumber: | 6012004645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2015 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | T-3198 | MS | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 25712 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.