Provider Demographics
NPI:1841888963
Name:GLENN, JARED PATRICK (AP)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:PATRICK
Last Name:GLENN
Suffix:
Gender:M
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 SCENIC GULF DR UNIT 7
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7022
Mailing Address - Country:US
Mailing Address - Phone:850-368-7872
Mailing Address - Fax:
Practice Address - Street 1:12273 US HIGHWAY 98 W STE 120
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-6945
Practice Address - Country:US
Practice Address - Phone:850-368-1685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3516171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist