Basic Information
| Provider Information | |||||||||
| NPI: | 1053755926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884425 | ||||||||
| FaxNumber: | 5025884427 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884450 | ||||||||
| FaxNumber: | 5025889539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | TP844 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 036158440 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1053755926 | 05 | KY | MEDICAID |