Provider Demographics
NPI:1295007243
Name:GLOVER, JESSICA M (LCSW, CADCI)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:GLOVER
Suffix:
Gender:F
Credentials:LCSW, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:5329 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:503-988-5183
Practice Address - Fax:503-988-5182
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10-06-18101YA0400X
ORL51481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR022959Medicaid
OR096511Medicaid