Provider Demographics
NPI:1811341159
Name:GLASS, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PEARTREE LN
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673-8720
Mailing Address - Country:US
Mailing Address - Phone:814-571-4594
Mailing Address - Fax:
Practice Address - Street 1:111 PEARTREE LN
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-8720
Practice Address - Country:US
Practice Address - Phone:814-571-4594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002198A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer