Provider Demographics
NPI:1750070363
Name:GLOVER, JESSICA BOSHAE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOSHAE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 JOHN AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATTALLA
Mailing Address - State:AL
Mailing Address - Zip Code:35954-3475
Mailing Address - Country:US
Mailing Address - Phone:256-490-6081
Mailing Address - Fax:
Practice Address - Street 1:940 GILBERT FERRY RD SE STE B
Practice Address - Street 2:
Practice Address - City:ATTALLA
Practice Address - State:AL
Practice Address - Zip Code:35954-3338
Practice Address - Country:US
Practice Address - Phone:256-781-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2023005133363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty