Provider Demographics
NPI:1790858751
Name:REYNOLDS, JEANMARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:JEANMARIE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2784 CORRAL EST
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-4102
Mailing Address - Country:US
Mailing Address - Phone:314-583-8377
Mailing Address - Fax:
Practice Address - Street 1:75 MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2625
Practice Address - Country:US
Practice Address - Phone:314-583-8377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000171103101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO001273705OtherCTS VENDOR NUMBER
MO494847809Medicaid
MO164436OtherBLUE CROSS BLUE SHIELD