Provider Demographics
NPI:1558633180
Name:REECE, JERRY W (LAC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:W
Last Name:REECE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11315 W CINDY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6542
Mailing Address - Country:US
Mailing Address - Phone:316-722-0146
Mailing Address - Fax:
Practice Address - Street 1:2707 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2249
Practice Address - Country:US
Practice Address - Phone:316-629-0249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS75101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100321990DMedicaid
KS17D0947647Medicare PIN