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NPI Code Detail

MEDICARE: JENNIFER DIANE GLISTA

MEDICARE: JENNIFER DIANE GLISTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1156FX1800XOpticianOP.017964-SOH

General Provider Information

NPI Number : 1770436396
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER DIANE GLISTA
Provider Business Mailing Address
First Line : 337 EWING RD
Second Line :
City : BOARDMAN
State : OH
Zip : 44512-3212
Country : US
Telephone Number : 330-758-0708
Fax Number : 330-758-1342
Provider Business Practice Location Address
First Line : 1300 DORAL DR
Second Line :
City : POLAND
State : OH
Zip : 44514-1900
Country : US
Telephone Number : 330-758-0708
Fax Number : 330-758-1342
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2026
Last Update Date : 02/16/2026

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Directions to “ JENNIFER DIANE GLISTA ” Practice Location

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