Provider Demographics
NPI:1528412210
Name:REYNOLDS, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6460
Mailing Address - Country:US
Mailing Address - Phone:507-385-6500
Mailing Address - Fax:507-385-6510
Practice Address - Street 1:101 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-385-6500
Practice Address - Fax:507-385-6510
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN62613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program