Provider Demographics
NPI:1699174615
Name:JASIMA REYNOLDS
Entity type:Organization
Organization Name:JASIMA REYNOLDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:JASIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-497-3573
Mailing Address - Street 1:1640 REDSTONE CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7605
Mailing Address - Country:US
Mailing Address - Phone:435-645-0788
Mailing Address - Fax:435-645-0792
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:435-645-0788
Practice Address - Fax:435-645-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012021460251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health