Provider Demographics
NPI:1215063805
Name:GLASS, JONATHAN M (LIC AC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:GLASS
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HEALING ESSENCE CENTER
Mailing Address - Street 2:50 BEHARREL STREET
Mailing Address - City:W. CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:508-369-9228
Mailing Address - Fax:
Practice Address - Street 1:HEALING ESSENCE CENTER
Practice Address - Street 2:50 BEHARREL STREET
Practice Address - City:WEST CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:508-369-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA495171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist