Basic Information
| Provider Information | |||||||||
| NPI: | 1679951503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935914 | ||||||||
| FaxNumber: | 6146856492 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938714 | ||||||||
| FaxNumber: | 6142933277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2015 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.17592 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | P01576650 | 01 | OH | RAILROAD MEDICARE | OTHER | 0142210 | 05 | OH | MEDICAID |