Provider Demographics
NPI:1508622507
Name:JETT, GLEN ALAN (RN)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ALAN
Last Name:JETT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4036
Mailing Address - Country:US
Mailing Address - Phone:925-349-5091
Mailing Address - Fax:
Practice Address - Street 1:2800 L ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:510-266-2996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA803762163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator