Provider Demographics
NPI:1538331277
Name:GLYNN, JESSE (PA-C, MMSC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GLYNN
Suffix:
Gender:F
Credentials:PA-C, MMSC
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:HARKNESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:51 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-2139
Mailing Address - Country:US
Mailing Address - Phone:401-837-1230
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:857-307-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1080541363AS0400X
MAPA2446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical