Provider Demographics
NPI:1710113543
Name:GLASS, JACOB RICHARD (D C)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RICHARD
Last Name:GLASS
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1636
Mailing Address - Country:US
Mailing Address - Phone:618-524-5151
Mailing Address - Fax:
Practice Address - Street 1:810 MARKET ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1636
Practice Address - Country:US
Practice Address - Phone:618-524-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor