Provider Demographics
NPI:1699271635
Name:REILLY, JEANNE (LAC)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 SAINT JOHNS PL APT 1B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5359
Mailing Address - Country:US
Mailing Address - Phone:646-641-4508
Mailing Address - Fax:
Practice Address - Street 1:15 W 26TH ST RM 10R
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1070
Practice Address - Country:US
Practice Address - Phone:646-641-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004941-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist