Healthcare Provider Details

I. General information

NPI: 1568301919
Provider Name (Legal Business Name): GLENN JAQUESS CALLAWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE CALLAWAY

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 ANTELOPE BLVD
RED BLUFF CA
96080-2443
US

IV. Provider business mailing address

490 ANTELOPE BLVD
RED BLUFF CA
96080-2443
US

V. Phone/Fax

Practice location:
  • Phone: 530-385-0080
  • Fax:
Mailing address:
  • Phone: 530-385-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: