Provider Demographics
NPI:1972979938
Name:GLASS, JENNIFER LEA COX (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEA COX
Last Name:GLASS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 FORT RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-8320
Mailing Address - Country:US
Mailing Address - Phone:808-780-4556
Mailing Address - Fax:
Practice Address - Street 1:15TH MDG
Practice Address - Street 2:755 SCOTT CIRCLE
Practice Address - City:JBPH-HICKAM AFB
Practice Address - State:HI
Practice Address - Zip Code:96853
Practice Address - Country:US
Practice Address - Phone:808-448-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA080005232103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical