Provider Demographics
NPI:1720731599
Name:GLENN, JERILYN CLAIRE (DHAT)
Entity Type:Individual
Prefix:MRS
First Name:JERILYN
Middle Name:CLAIRE
Last Name:GLENN
Suffix:
Gender:F
Credentials:DHAT
Other - Prefix:
Other - First Name:JERILYN
Other - Middle Name:CLAIRE
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 977
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0977
Mailing Address - Country:US
Mailing Address - Phone:907-744-3359
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDY HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-9955
Practice Address - Country:US
Practice Address - Phone:907-744-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK22-162-DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist