Healthcare Provider Details

I. General information

NPI: 1629881057
Provider Name (Legal Business Name): JONATHAN BAILEY REECER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BETSY WAY
GEORGETOWN KY
40324-0557
US

IV. Provider business mailing address

100 PARK CREST CT APT 4
RICHMOND KY
40475-8383
US

V. Phone/Fax

Practice location:
  • Phone: 931-267-3555
  • Fax:
Mailing address:
  • Phone: 931-267-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2200
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: