Provider Demographics
NPI:1962420547
Name:GLENN, JASON A (PA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:A
Last Name:GLENN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE STE 130
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2252
Practice Address - Country:US
Practice Address - Phone:417-820-5150
Practice Address - Fax:417-820-5155
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2003025739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ03820Medicare UPIN
MO000097499Medicare PIN
MO000097066Medicare PIN