Healthcare Provider Details

I. General information

NPI: 1255725743
Provider Name (Legal Business Name): JASON D REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

IV. Provider business mailing address

216 S 3RD ST APT 2
BROOKLYN NY
11211-5602
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-1183
  • Fax:
Mailing address:
  • Phone: 716-485-8637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: