Provider Demographics
NPI:1720583537
Name:GLIDEWELL, JESSICA LEIGH
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LEIGH
Last Name:GLIDEWELL
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 1:4702 W GRACE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3722
Mailing Address - Country:US
Mailing Address - Phone:804-839-0344
Mailing Address - Fax:
Practice Address - Street 1:7114 COPLE HWY
Practice Address - Street 2:
Practice Address - City:HAGUE
Practice Address - State:VA
Practice Address - Zip Code:22469-2525
Practice Address - Country:US
Practice Address - Phone:804-472-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist