Provider Demographics
NPI:1073254769
Name:REYNOLDS, JAKE CULLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:CULLEN
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 1:18818 TELLER AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8884
Mailing Address - Country:US
Mailing Address - Phone:949-535-2322
Mailing Address - Fax:
Practice Address - Street 1:18818 TELLER AVE STE 170
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-8884
Practice Address - Country:US
Practice Address - Phone:949-535-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor