Provider Demographics
NPI:1790806107
Name:GLIDEWELL, JESSICA NICOLE (MHPP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 TOLLETT RD
Mailing Address - Street 2:
Mailing Address - City:NEWHOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71959-8017
Mailing Address - Country:US
Mailing Address - Phone:870-398-4536
Mailing Address - Fax:
Practice Address - Street 1:1575 HIGHWAY 371 W
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-7598
Practice Address - Country:US
Practice Address - Phone:870-451-9742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator