Provider Demographics
NPI:1184855058
Name:GLYNN, JENNA LEIGH (DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:GLYNN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LEIGH
Other - Last Name:WICKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23000 MOAKLEY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2916
Mailing Address - Country:US
Mailing Address - Phone:301-475-5555
Mailing Address - Fax:
Practice Address - Street 1:23000 MOAKLEY ST STE 102
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2916
Practice Address - Country:US
Practice Address - Phone:301-475-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28314225100000X
NC12600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212810Medicaid
2506180Medicare UPIN