Provider Demographics
NPI:1922360668
Name:REYNGOUDT, JEANNINE ROSE
Entity Type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:ROSE
Last Name:REYNGOUDT
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 1:60 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2795
Mailing Address - Country:US
Mailing Address - Phone:607-753-5028
Mailing Address - Fax:607-753-5136
Practice Address - Street 1:60 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2795
Practice Address - Country:US
Practice Address - Phone:607-753-5028
Practice Address - Fax:607-753-5136
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist