Provider Demographics
NPI:1588171037
Name:GLASS, JADE A (ATC)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:A
Last Name:GLASS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CAMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-2603
Mailing Address - Country:US
Mailing Address - Phone:334-399-2211
Mailing Address - Fax:
Practice Address - Street 1:700 HYUNDAI BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36105-9622
Practice Address - Country:US
Practice Address - Phone:334-387-8421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
AL21522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program