Provider Demographics
NPI:1770196701
Name:GLASS, JACQUELIEN (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELIEN
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 SPRING HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1402
Mailing Address - Country:US
Mailing Address - Phone:251-435-1367
Mailing Address - Fax:
Practice Address - Street 1:1725 SPRING HILL AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1402
Practice Address - Country:US
Practice Address - Phone:251-435-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-118675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily