Provider Demographics
NPI:1659334290
Name:GLANCE, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GLANCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 S MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-2467
Practice Address - Country:US
Practice Address - Phone:419-586-5170
Practice Address - Fax:419-586-5177
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013945207V00000X
OH34008744207VB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VB0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObesity Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1659334290Medicaid
MI700G410560OtherBLUE CROSS
MI1659334290Medicaid
H84730Medicare UPIN
OH2643358Medicaid
OHH033130Medicare PIN
OH4181631Medicare PIN
H84730Medicare UPIN
OH34008744OtherOH MEDICAL LICENSE
OHH84730Medicare UPIN