Provider Demographics
NPI:1417272030
Name:GLENN, JOHN EDWARD (LMP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:GLENN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3202
Mailing Address - Country:US
Mailing Address - Phone:253-790-9701
Mailing Address - Fax:
Practice Address - Street 1:1434 29TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3202
Practice Address - Country:US
Practice Address - Phone:253-790-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60135797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty