Healthcare Provider Details

I. General information

NPI: 1295375293
Provider Name (Legal Business Name): JACKIE JOY GLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 SE 9TH AVE
POMPANO BEACH FL
33060-9508
US

IV. Provider business mailing address

996 SE 9TH AVE
POMPANO BEACH FL
33060-9508
US

V. Phone/Fax

Practice location:
  • Phone: 954-309-7519
  • Fax:
Mailing address:
  • Phone: 954-309-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSW4845
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: