Provider Demographics
NPI:1285269662
Name:HALL, JACK REYNOLDS III
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:REYNOLDS
Last Name:HALL
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6339 MIDDLE GROUND RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-8434
Mailing Address - Country:US
Mailing Address - Phone:912-682-2367
Mailing Address - Fax:
Practice Address - Street 1:6339 MIDDLE GROUND RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-8434
Practice Address - Country:US
Practice Address - Phone:912-682-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer