Provider Demographics
NPI:1598336653
Name:JONES, GLENN MICHAEL
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MICHAEL
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48490 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8675
Mailing Address - Country:US
Mailing Address - Phone:734-576-1365
Mailing Address - Fax:248-284-7525
Practice Address - Street 1:48490 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-8675
Practice Address - Country:US
Practice Address - Phone:734-576-1365
Practice Address - Fax:248-284-7525
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant