Provider Demographics
NPI:1174929491
Name:JERNIGAN, REILLY (LAC)
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:JERNIGAN
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 1:910 PLATEAU RD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-7615
Mailing Address - Country:US
Mailing Address - Phone:970-596-7585
Mailing Address - Fax:
Practice Address - Street 1:910 PLATEAU RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-7615
Practice Address - Country:US
Practice Address - Phone:970-596-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001867171100000X
COMT.0004081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist