Healthcare Provider Details

I. General information

NPI: 1932612116
Provider Name (Legal Business Name): JESSICA T GLENN MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SPRINGFIELD ST
DAYTON OH
45431-1084
US

IV. Provider business mailing address

200 S KEOWEE ST
DAYTON OH
45402-2242
US

V. Phone/Fax

Practice location:
  • Phone: 937-236-9965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT007762
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: