Provider Demographics
NPI:1730715376
Name:GLENN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48744-0034
Mailing Address - Country:US
Mailing Address - Phone:989-372-0271
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 34
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:MI
Practice Address - Zip Code:48744-0034
Practice Address - Country:US
Practice Address - Phone:989-372-0271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101YM0800X, 101YP2500X, 1041C0700X, 101Y00000X, 101YA0400X
MI68011148921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)