Provider Demographics
NPI:1033384128
Name:WIDICK, REGINALD JACK
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:JACK
Last Name:WIDICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 FRANKLIN RD
Mailing Address - Street 2:SUITE 135A-121
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3280
Mailing Address - Country:US
Mailing Address - Phone:270-745-7182
Mailing Address - Fax:
Practice Address - Street 1:330 FRANKLIN RD
Practice Address - Street 2:SUITE 135A-121
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3280
Practice Address - Country:US
Practice Address - Phone:270-745-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN615237700000X
KY834237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist