Provider Demographics
NPI:1326320656
Name:GLASS, JACI R (NP)
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:R
Last Name:GLASS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACI
Other - Middle Name:R
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1199 HADLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1788
Practice Address - Country:US
Practice Address - Phone:317-834-3263
Practice Address - Fax:317-834-5194
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28174021A363LA2200X
IN71003660A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201035270Medicaid
IN151560064Medicare PIN
IN201035270Medicaid
IN264430387Medicare PIN