Healthcare Provider Details

I. General information

NPI: 1811922941
Provider Name (Legal Business Name): JODI L GLASS AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 4TH ST
PROVIDENCE RI
02906-3754
US

IV. Provider business mailing address

254 4TH ST
PROVIDENCE RI
02906-3754
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-4292
  • Fax:
Mailing address:
  • Phone: 401-272-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD00029
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: