Provider Demographics
NPI:1477855211
Name:GLASS, JENNIFER L
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 65TH STREET CT NW
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-1637
Mailing Address - Country:US
Mailing Address - Phone:941-773-7620
Mailing Address - Fax:
Practice Address - Street 1:404 65TH STREET CT NW
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-1637
Practice Address - Country:US
Practice Address - Phone:941-807-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist