Healthcare Provider Details

I. General information

NPI: 1457292708
Provider Name (Legal Business Name): JADA MICHELLE GLENN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

777 HEMLOCK ST
MACON GA
31201-2102
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-5437
  • Fax:
Mailing address:
  • Phone: 904-252-6814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113637
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: