Provider Demographics
NPI:1861786345
Name:REYNOLDS, JESSICA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2995 REIDVILLE RD STE 210
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5631
Practice Address - Country:US
Practice Address - Phone:864-253-8140
Practice Address - Fax:864-587-0051
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCLL33622207R00000X
SC33622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC77205019OtherMEDICARE PIN
SC336229Medicaid