Provider Demographics
NPI:1447474309
Name:MCREYNOLDS, JENNIFER (ST)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 EAGLE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-7960
Mailing Address - Country:US
Mailing Address - Phone:817-706-9294
Mailing Address - Fax:
Practice Address - Street 1:4701 EAGLE TRACE DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-7960
Practice Address - Country:US
Practice Address - Phone:817-706-9294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100182OtherSTATE LICENSE NUMBER