Provider Demographics
NPI:1114475498
Name:GLOVER, JONATHAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GLOVER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15650 N 19TH AVE UNIT 1197
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4354
Mailing Address - Country:US
Mailing Address - Phone:530-917-5576
Mailing Address - Fax:
Practice Address - Street 1:15650 N 19TH AVE UNIT 1197
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4354
Practice Address - Country:US
Practice Address - Phone:530-917-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15178225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist