Provider Demographics
NPI:1225019680
Name:GLOCK, JENNIFER L (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GLOCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10232 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-6203
Mailing Address - Country:US
Mailing Address - Phone:904-260-0218
Mailing Address - Fax:904-292-1094
Practice Address - Street 1:10232 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6203
Practice Address - Country:US
Practice Address - Phone:904-260-0218
Practice Address - Fax:904-292-1094
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z2981Medicare ID - Type Unspecified