Provider Demographics
NPI:1659703338
Name:REYNOLDS, JADE CHAMPAGNE
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:CHAMPAGNE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 NW 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-1321
Mailing Address - Country:US
Mailing Address - Phone:954-298-1379
Mailing Address - Fax:
Practice Address - Street 1:12545 ORANGE DR
Practice Address - Street 2:SUITE 502
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4306
Practice Address - Country:US
Practice Address - Phone:954-474-8048
Practice Address - Fax:954-474-8145
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6305235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist