Healthcare Provider Details

I. General information

NPI: 1568549129
Provider Name (Legal Business Name): JACQUE L. REYNOLDS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E HOSPITAL RD
EL DORADO SPRINGS MO
64744-2021
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-876-5851
  • Fax: 417-876-5484
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: