Provider Demographics
NPI:1972380350
Name:GLAZE, JAWAUNN QUINDELL SR
Entity Type:Individual
Prefix:
First Name:JAWAUNN
Middle Name:QUINDELL
Last Name:GLAZE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10847 NE 8TH TERRACE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5308
Mailing Address - Country:US
Mailing Address - Phone:405-408-0689
Mailing Address - Fax:
Practice Address - Street 1:1414 SW 89TH ST STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6312
Practice Address - Country:US
Practice Address - Phone:405-676-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator