Healthcare Provider Details

I. General information

NPI: 1689233827
Provider Name (Legal Business Name): JACKLYN MARIE REIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 VETERANS MEMORIAL PKWY BLDG 10
EAST PROVIDENCE RI
02914-5300
US

IV. Provider business mailing address

296 HIGHLAND AVE
WESTPORT MA
02790-2207
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-6888
  • Fax:
Mailing address:
  • Phone: 508-496-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01151
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: