Provider Demographics
NPI:1396252243
Name:REARDON, JACK EDWARD
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:REARDON
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 1:644 E MEYERS AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-3508
Mailing Address - Country:US
Mailing Address - Phone:586-703-9701
Mailing Address - Fax:
Practice Address - Street 1:1301 GREYTHORNE DR
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2437
Practice Address - Country:US
Practice Address - Phone:248-520-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide