Provider Demographics
NPI:1407995848
Name:GLENN, JASON (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 TOWNE CENTER DRIVE
Mailing Address - Street 2:#116
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511
Mailing Address - Country:US
Mailing Address - Phone:859-552-7403
Mailing Address - Fax:
Practice Address - Street 1:124 TOWNE CENTER DRIVE
Practice Address - Street 2:#116
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511
Practice Address - Country:US
Practice Address - Phone:859-552-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1685DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000510977OtherANTHEM BCBS
KY7100030660Medicaid
KY000000510977OtherANTHEM BCBS
KYV07200Medicare UPIN
KY0941017Medicare PIN
KY5419240005Medicare NSC