Provider Demographics
NPI:1144940917
Name:REYNOLDS, JADI JO (LAC)
Entity type:Individual
Prefix:
First Name:JADI
Middle Name:JO
Last Name:REYNOLDS
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0150
Mailing Address - Country:US
Mailing Address - Phone:509-634-2610
Mailing Address - Fax:
Practice Address - Street 1:11614 S HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:WA
Practice Address - Zip Code:99140-9537
Practice Address - Country:US
Practice Address - Phone:509-634-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT50568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)