Provider Demographics
NPI:1477641165
Name:REYNOLDS, JEFFREY C (LCPC PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LCPC PHD
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 162
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-0162
Mailing Address - Country:US
Mailing Address - Phone:217-379-4302
Mailing Address - Fax:217-817-0379
Practice Address - Street 1:1510 W OTTAWA
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957
Practice Address - Country:US
Practice Address - Phone:217-379-4302
Practice Address - Fax:217-379-4306
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004199101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180004199OtherLCPC