Provider Demographics
NPI:1972852879
Name:REYNOLDS, JACK (LVN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 VIA BAJA
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1240
Mailing Address - Country:US
Mailing Address - Phone:805-760-7179
Mailing Address - Fax:
Practice Address - Street 1:194 VIA BAJA
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1240
Practice Address - Country:US
Practice Address - Phone:805-760-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 265668164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse