Provider Demographics
NPI:1043681349
Name:GLENN, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 LEWISBURG RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-9455
Mailing Address - Country:US
Mailing Address - Phone:501-743-6855
Mailing Address - Fax:
Practice Address - Street 1:1300 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-743-6855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist