Provider Demographics
NPI:1881734523
Name:KIECOLT-GLASER, JANICE K (PHD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:K
Last Name:KIECOLT-GLASER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 OLD POSTE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-4905
Mailing Address - Country:US
Mailing Address - Phone:614-771-9119
Mailing Address - Fax:614-293-8552
Practice Address - Street 1:1670 UPHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1250
Practice Address - Country:US
Practice Address - Phone:614-293-4586
Practice Address - Fax:614-293-8552
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2764103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0397431Medicaid
OH2764OtherLICENSE
OH2764OtherLICENSE