Individual
JORELL GLASS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
456 FULTON ST STE 180, PEORIA, IL 61602-1292
(309) 408-9399
Mailing address
1321 W MAYWOOD AVE, PEORIA, IL 61604-2548
Taxonomy
Speciality
Code
Description
License number
State
1744P3200X
Prosthetics Case Management
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1744P3200X
CERTIFIED HAIR LOSS SPECIALIST
IL
Enumeration date
05/06/2019
Last updated
05/06/2019
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