Healthcare Provider Details

I. General information

NPI: 1336609767
Provider Name (Legal Business Name): ZACHERY AARON GLENN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2005
  • Fax: 601-815-0434
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number29584
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: