Provider Demographics
NPI:1992889075
Name:REYNOLDS, JENNIFER (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4911
Mailing Address - Country:US
Mailing Address - Phone:812-945-1162
Mailing Address - Fax:812-945-5592
Practice Address - Street 1:1501 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4911
Practice Address - Country:US
Practice Address - Phone:812-945-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1670DT152W00000X
IN18003416A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200868720Medicaid
INP00766631OtherRR MEDICARE
KY000000510856OtherANTHEM BCBS
KY7100002840Medicaid
KYV11146Medicare UPIN
INP00766631OtherRR MEDICARE
IN200868720Medicaid
KY7100002840Medicaid
IN5419240009Medicare NSC