Provider Demographics
NPI:1861715690
Name:GLOVER, JONATHAN (CCS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GLOVER
Suffix:
Gender:M
Credentials:CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 PONY DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-9159
Mailing Address - Country:US
Mailing Address - Phone:850-515-0220
Mailing Address - Fax:850-515-0260
Practice Address - Street 1:703 W 3RD AVE
Practice Address - Street 2:#B
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-1524
Practice Address - Country:US
Practice Address - Phone:850-515-0220
Practice Address - Fax:850-515-0260
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC603368101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110583Medicaid