Basic Information
| Provider Information | |||||||||
| NPI: | 1902047350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ALIMARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICAL THERAPY ASS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEY | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ALIMARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 727 | ||||||||
| Address2: | 304 JACOBS HWY | ||||||||
| City: | CLINTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648332550 | ||||||||
| FaxNumber: | 8649389240 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 JACOBS HWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648332550 | ||||||||
| FaxNumber: | 8649389240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2009 | ||||||||
| LastUpdateDate: | 03/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | SPECIALIST 183 | SC | Y | Other Service Providers | Specialist |
No ID Information.