Healthcare Provider Details

I. General information

NPI: 1811425853
Provider Name (Legal Business Name): JARED REICHARD NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 SUNRISE DR
GRANTVILLE GA
30220-2854
US

IV. Provider business mailing address

643 MAIN ST
PALMETTO GA
30268-1138
US

V. Phone/Fax

Practice location:
  • Phone: 770-312-5137
  • Fax:
Mailing address:
  • Phone: 404-929-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN225678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: