Provider Demographics
NPI:1912317587
Name:REDDICK, JACOB WILLARD (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLARD
Last Name:REDDICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 63RD STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424
Mailing Address - Country:US
Mailing Address - Phone:806-785-0600
Mailing Address - Fax:806-785-0606
Practice Address - Street 1:5807 63RD STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424
Practice Address - Country:US
Practice Address - Phone:806-785-0600
Practice Address - Fax:806-785-0606
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAT5828009-960207Q00000X
TXQ6092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ6092OtherTEXAS MEDICAL BOARD