Provider Demographics
NPI:1710435433
Name:REYNOLDS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6170 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-4217
Mailing Address - Country:US
Mailing Address - Phone:734-512-9296
Mailing Address - Fax:
Practice Address - Street 1:6170 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-4217
Practice Address - Country:US
Practice Address - Phone:734-512-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other