Provider Demographics
NPI:1821182320
Name:GLENN, JACQUELINE CHANNELLE (RN,MSN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:CHANNELLE
Last Name:GLENN
Suffix:
Gender:F
Credentials:RN,MSN
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:MARQUITO
Other - Last Name:CHANNELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN
Mailing Address - Street 1:249 BILLINGSLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-336-4662
Mailing Address - Fax:704-331-0859
Practice Address - Street 1:249 BILLINGSLEY ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-336-4662
Practice Address - Fax:704-331-0859
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC050671163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01023OtherHEALTH DEPARTMENT