Provider Demographics
NPI:1750022927
Name:GLASS, JORDAN MARSHALL (DO)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARSHALL
Last Name:GLASS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 RIDGEWALK LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-1868
Mailing Address - Country:US
Mailing Address - Phone:432-349-9935
Mailing Address - Fax:
Practice Address - Street 1:144 N RAVENEL ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2641
Practice Address - Country:US
Practice Address - Phone:843-777-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-04
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1750022927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine