Provider Demographics
NPI:1679940050
Name:GLAZA, JACQUELINE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:GLAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-3805
Mailing Address - Country:US
Mailing Address - Phone:702-249-2135
Mailing Address - Fax:
Practice Address - Street 1:2700 E SUNSET RD
Practice Address - Street 2:SUITE 24
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3506
Practice Address - Country:US
Practice Address - Phone:702-635-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-15-02742103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst