Provider Demographics
NPI:1083634620
Name:GLADE, JASON S (NP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:GLADE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD SUITE 203
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:1268 LEE BOULEVARD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-2660
Practice Address - Fax:509-942-3836
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT309994-4405363L00000X
WAAP30007491363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083634620Medicaid
500030524OtherPALMETTO
WA0335446OtherLABOR & INDUSTRIES
UT30999444000001OtherBCBS OF UTAH
WAG8889768Medicare PIN
UTP76449Medicare UPIN