Basic Information
| Provider Information | |||||||||
| NPI: | 1912317587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDICK | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY STE 35 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067820097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 N AVENUE S | ||||||||
| Address2: | |||||||||
| City: | POST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793562115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064952583 | ||||||||
| FaxNumber: | 8064953576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2014 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AT5828009-960 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | Q6092 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q6092 | 01 | TX | TEXAS MEDICAL BOARD | OTHER |