Provider Demographics
NPI:1013903921
Name:GLASS, JESSICA LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:GLASS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CHEATHAM ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-2828
Mailing Address - Country:US
Mailing Address - Phone:615-212-0082
Mailing Address - Fax:
Practice Address - Street 1:709 CHEATHAM ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2828
Practice Address - Country:US
Practice Address - Phone:615-212-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3993A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74000613Medicaid
TN4205845OtherBLUE CROSS BLUE SHIELD OF TENNESSEE
TN4205845OtherBLUE CROSS BLUE SHIELD OF TENNESSEE
TN36385431Medicare PIN