Healthcare Provider Details

I. General information

NPI: 1972979938
Provider Name (Legal Business Name): JENNIFER LEA COX GLASS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 09/26/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15TH MDG 755 SCOTT CIRCLE
JBPH-HICKAM AFB HI
96853
US

IV. Provider business mailing address

1898 FORT RD
SHERIDAN WY
82801-8320
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6377
  • Fax:
Mailing address:
  • Phone: 808-780-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number080005232
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: