Provider Demographics
NPI:1346387123
Name:REICHARDT, JEFFREY A (NP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:REICHARDT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 BATON ROUGE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-5104
Mailing Address - Country:US
Mailing Address - Phone:419-331-2273
Mailing Address - Fax:419-331-4274
Practice Address - Street 1:2440 BATON ROUGE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-5104
Practice Address - Country:US
Practice Address - Phone:419-331-2273
Practice Address - Fax:419-331-4274
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10079.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4775429Medicaid
OHN84570013Medicare PIN