Provider Demographics
NPI:1760518120
Name:REYNA, JAIME S (DC)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:S
Last Name:REYNA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 E SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704
Mailing Address - Country:US
Mailing Address - Phone:559-225-2859
Mailing Address - Fax:559-225-2931
Practice Address - Street 1:1445 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-5138
Practice Address - Country:US
Practice Address - Phone:559-225-2859
Practice Address - Fax:559-225-2931
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0200550Medicaid
CADC0200550Medicaid