Provider Demographics
NPI:1023072170
Name:GLUCK, JEANETTE MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:MARIE
Last Name:GLUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5070 MINTON RD NW STE 3
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1157
Mailing Address - Country:US
Mailing Address - Phone:321-768-1600
Mailing Address - Fax:321-435-0100
Practice Address - Street 1:5070 MINTON RD NW STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1157
Practice Address - Country:US
Practice Address - Phone:321-768-1600
Practice Address - Fax:321-255-2361
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY07HYOtherFLORIDA BLUE