Provider Demographics
NPI:1386274330
Name:REAVES, JENNIFER M (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:REAVES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PECAN PARK RD # 529
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-1602
Mailing Address - Country:US
Mailing Address - Phone:954-479-6805
Mailing Address - Fax:
Practice Address - Street 1:4540 SOUTHSIDE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5492
Practice Address - Country:US
Practice Address - Phone:904-296-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL67698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty