Basic Information
| Provider Information | |||||||||
| NPI: | 1295007243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOVER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW, CADCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 5329 NE MARTIN LUTHER KING BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972113237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885183 | ||||||||
| FaxNumber: | 5039885182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2012 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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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 | 101YA0400X | 10-06-18 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | L5148 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 096511 | 05 | OR | MEDICAID | 022959 | 05 | OR | MEDICAID |