Provider Demographics
NPI:1003021759
Name:REYNOLDS, JACKIE SUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:SUE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 TROTTERS CIR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3373
Mailing Address - Country:US
Mailing Address - Phone:740-990-8832
Mailing Address - Fax:
Practice Address - Street 1:199 TROTTERS CIR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-3373
Practice Address - Country:US
Practice Address - Phone:740-990-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN090469164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse