Healthcare Provider Details

I. General information

NPI: 1033415849
Provider Name (Legal Business Name): JACQUELYN R. GLEATON S.L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S BASCOM AVE SUITE 8
SAN JOSE CA
95128-3509
US

IV. Provider business mailing address

1150 S BASCOM AVE SUITE 8
SAN JOSE CA
95128-3509
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-9000
  • Fax: 408-885-9009
Mailing address:
  • Phone: 408-885-9000
  • Fax: 408-885-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: