Healthcare Provider Details

I. General information

NPI: 1598271793
Provider Name (Legal Business Name): JACLYN L GLASER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7180 10TH ST N
OAKDALE MN
55128-1122
US

IV. Provider business mailing address

2025 SLOAN PL STE 35
SAINT PAUL MN
55117-2092
US

V. Phone/Fax

Practice location:
  • Phone: 651-242-5890
  • Fax: 651-731-6207
Mailing address:
  • Phone: 651-772-1572
  • Fax: 651-772-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12598
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: