Basic Information
| Provider Information | |||||||||
| NPI: | 1205105731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 232410 | ||||||||
| Address2: | CLINIC TOWER, 7TH FLOOR A7D | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921932410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195436164 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709629977 | ||||||||
| FaxNumber: | 7703399804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A119307 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 85849 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.