Provider Demographics
NPI:1386042679
Name:GLIDER, JANN (PHD)
Entity Type:Individual
Prefix:
First Name:JANN
Middle Name:
Last Name:GLIDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 E LANCASTER AVE APT C1
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-2348
Mailing Address - Country:US
Mailing Address - Phone:215-514-2130
Mailing Address - Fax:
Practice Address - Street 1:6811 QUINCY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2663
Practice Address - Country:US
Practice Address - Phone:215-514-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 004336-L103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent