=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376320531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY D REYNOLDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2023
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16627 PABLO ISLAND DRIVE
-----------------------------------------------------
City | GROVELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34736-9238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-777-9887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16627 PABLO ISLAND DRIVE
-----------------------------------------------------
City | GROVELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34736-9238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-777-9887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY D REYNOLDS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 352-777-9887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------