Provider Demographics
NPI:1588163588
Name:REICHERT, JACOB JAMES
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JAMES
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 1:7727 111TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3205
Mailing Address - Country:US
Mailing Address - Phone:763-439-6939
Mailing Address - Fax:
Practice Address - Street 1:150 10TH ST NW
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1737
Practice Address - Country:US
Practice Address - Phone:320-983-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant