Provider Demographics
NPI:1477788461
Name:GLOVER, JEFF (MA LADC)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:GLOVER
Suffix:
Gender:M
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 FORESTVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-5910
Mailing Address - Country:US
Mailing Address - Phone:763-542-9212
Mailing Address - Fax:763-542-9248
Practice Address - Street 1:1517 HIGHWAY 13 E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2917
Practice Address - Country:US
Practice Address - Phone:952-890-8879
Practice Address - Fax:952-890-8920
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301797101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor