Provider Demographics
NPI:1831272822
Name:GLENN, JACQUELYN KAY (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:KAY
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELYN
Other - Middle Name:KAY
Other - Last Name:O'HERRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14100 E ARAPAHOE RD
Mailing Address - Street 2:STE 260
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4048
Mailing Address - Country:US
Mailing Address - Phone:720-612-1912
Mailing Address - Fax:303-736-4226
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 309
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:720-820-9455
Practice Address - Fax:303-736-4226
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40730-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39557272Medicaid