Provider Demographics
NPI:1194531079
Name:REICHERT, JAEDYN ZACHARY
Entity type:Individual
Prefix:
First Name:JAEDYN
Middle Name:ZACHARY
Last Name:REICHERT
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 1:171 DEEP WOOD DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4935
Mailing Address - Country:US
Mailing Address - Phone:512-910-3251
Mailing Address - Fax:
Practice Address - Street 1:171 DEEP WOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4935
Practice Address - Country:US
Practice Address - Phone:512-910-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician