Provider Demographics
NPI:1124260666
Name:REYNOLDS, JENNIFER A (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2538
Mailing Address - Country:US
Mailing Address - Phone:503-788-3800
Mailing Address - Fax:503-788-8020
Practice Address - Street 1:6501 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2538
Practice Address - Country:US
Practice Address - Phone:503-788-3800
Practice Address - Fax:503-788-8020
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7605172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist