Provider Demographics
NPI:1568549129
Name:REYNOLDS, JACQUE L (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUE
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:309 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-2021
Practice Address - Country:US
Practice Address - Phone:417-876-5851
Practice Address - Fax:417-876-5484
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR8648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240578617Medicaid
MO061013230Medicare PIN
MOD41748Medicare UPIN
MO240578617Medicaid