Provider Demographics
NPI:1407995848
Name:GLENN, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 MIDLAND TRL
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1638
Mailing Address - Country:US
Mailing Address - Phone:502-633-2985
Mailing Address - Fax:502-647-0327
Practice Address - Street 1:10232 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2148
Practice Address - Country:US
Practice Address - Phone:502-339-2042
Practice Address - Fax:502-736-4490
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1685DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100030660Medicaid
KY000000510977OtherANTHEM BCBS
KY000000510977OtherANTHEM BCBS
KYV07200Medicare UPIN
KY0941017Medicare PIN
KY5419240005Medicare NSC