=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679754188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED WAYNE REAVES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2007
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10816 HICKORY RIDGE RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-306-2217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6029 WATCH CHAIN WAY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-4714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-306-2217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 0101249265
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | D0074865
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------