Provider Demographics
NPI:1992543094
Name:REYNOLDS, JARED (PLADC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-2651
Mailing Address - Country:US
Mailing Address - Phone:970-260-7197
Mailing Address - Fax:
Practice Address - Street 1:8260 HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-2651
Practice Address - Country:US
Practice Address - Phone:970-260-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1936101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor