Healthcare Provider Details

I. General information

NPI: 1508622507
Provider Name (Legal Business Name): GLEN ALAN JETT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 L ST
SACRAMENTO CA
95816-5616
US

IV. Provider business mailing address

1215 REDWOOD DR
CONCORD CA
94520-4036
US

V. Phone/Fax

Practice location:
  • Phone: 510-266-2996
  • Fax:
Mailing address:
  • Phone: 925-349-5091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number803762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: