Provider Demographics
NPI:1326320656
Name:GLASS, JACI R (NP)
Entity type:Individual
Prefix:
First Name:JACI
Middle Name:R
Last Name:GLASS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACI
Other - Middle Name:R
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6890 COLLISI PL
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9134
Mailing Address - Country:US
Mailing Address - Phone:317-835-1370
Mailing Address - Fax:
Practice Address - Street 1:6890 COLLISI PL
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-9134
Practice Address - Country:US
Practice Address - Phone:317-835-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003660A363LA2200X
IN28174021A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201035270Medicaid
IN151560064Medicare PIN
IN201035270Medicaid
IN264430387Medicare PIN