Provider Demographics
NPI:1871946715
Name:GLYNN, JENNIFER S (MACOM, LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:GLYNN
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17635 HENDERSON PASS
Mailing Address - Street 2:APT 922
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1647
Mailing Address - Country:US
Mailing Address - Phone:210-504-9272
Mailing Address - Fax:
Practice Address - Street 1:16607 BLANCO RD
Practice Address - Street 2:SUITE 12202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1913
Practice Address - Country:US
Practice Address - Phone:210-504-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist