Provider Demographics
NPI:1003874645
Name:REYNOLDS, JADE MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:JADE
Middle Name:MATTHEW
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WIND RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:BERNE
Mailing Address - State:IN
Mailing Address - Zip Code:46711-2375
Mailing Address - Country:US
Mailing Address - Phone:260-589-3256
Mailing Address - Fax:260-589-3587
Practice Address - Street 1:430 WIND RIDGE TRL
Practice Address - Street 2:
Practice Address - City:BERNE
Practice Address - State:IN
Practice Address - Zip Code:46711-2375
Practice Address - Country:US
Practice Address - Phone:260-589-3256
Practice Address - Fax:260-589-3587
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002103A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231630Medicare ID - Type Unspecified