Basic Information
| Provider Information | |||||||||
| NPI: | 1528077518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLADDEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 N CALIFORNIA BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945963742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252255837 | ||||||||
| FaxNumber: | 9254822834 | ||||||||
| Practice Location | |||||||||
| Address1: | 1065 BUCKS LAKE RD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959719507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302832121 | ||||||||
| FaxNumber: | 5302833151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | G60792 | CA | N | Emergency Medical Service Providers | Personal Emergency Response Attendant | 207P00000X | G60792 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G607920 | 05 | CA | MEDICAID | CA644Z | 05 | CA | MEDICAID |