Healthcare Provider Details

I. General information

NPI: 1548184708
Provider Name (Legal Business Name): JENECIA REED LDO003136
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 NORTHSIDE DR E
STATESBORO GA
30458-4760
US

IV. Provider business mailing address

147 NORTHSIDE DR E
STATESBORO GA
30458-4760
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-7914
  • Fax: 912-764-7352
Mailing address:
  • Phone: 912-764-7914
  • Fax: 912-764-7352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO003136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: