Provider Demographics
NPI:1386917078
Name:REYNOLDS, JOHN W (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20174 FRONT ST NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7445
Mailing Address - Country:US
Mailing Address - Phone:360-697-1141
Mailing Address - Fax:360-697-2395
Practice Address - Street 1:20174 FRONT ST NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7445
Practice Address - Country:US
Practice Address - Phone:360-697-1141
Practice Address - Fax:360-697-2395
Is Sole Proprietor?:No
Enumeration Date:2012-02-12
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60245862103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist