Provider Demographics
NPI:1225323827
Name:REYNOLDS, REBECCA J (LPC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5656 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-9641
Mailing Address - Country:US
Mailing Address - Phone:903-589-9000
Mailing Address - Fax:903-589-3443
Practice Address - Street 1:3320 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6984
Practice Address - Country:US
Practice Address - Phone:903-723-6136
Practice Address - Fax:903-589-3443
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65692101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283546401Medicaid