MEDICARE: JESSICA GLENN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP009224	GA
2	235Z00000X	Speech-Language Pathologist	3708	AL

General Provider Information

NPI Number	:	1952752966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GLENN

Provider Business Mailing Address
First Line	:	3516 SPRING VIEW CT
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30004-8907
Country	:	US
Telephone Number	:	563-543-7466
Fax Number	:

Provider Business Practice Location Address
First Line	:	3516 SPRING VIEW CT
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30004-8907
Country	:	US
Telephone Number	:	563-543-7466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	06/30/2016

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Directions to “ JESSICA GLENN ” Practice Location

Language	Start Address	Practice Location

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