Provider Demographics
NPI:1912317587
Name:REDDICK, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:REDDICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY STE 35
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3545
Mailing Address - Country:US
Mailing Address - Phone:806-761-0333
Mailing Address - Fax:806-782-0097
Practice Address - Street 1:1104 N AVENUE S
Practice Address - Street 2:
Practice Address - City:POST
Practice Address - State:TX
Practice Address - Zip Code:79356-2115
Practice Address - Country:US
Practice Address - Phone:806-495-2583
Practice Address - Fax:806-495-3576
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT5828009-960207Q00000X
TXQ6092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ6092OtherTEXAS MEDICAL BOARD