Provider Demographics
NPI:1720615248
Name:REAUME, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:REAUME
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:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-0782
Mailing Address - Country:US
Mailing Address - Phone:903-530-8177
Mailing Address - Fax:
Practice Address - Street 1:16911 VILLAGE LAKE DR
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-5065
Practice Address - Country:US
Practice Address - Phone:903-882-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2042331225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant