Provider Demographics
NPI:1598572893
Name:GLOVER, JAKWONTEZ L
Entity type:Individual
Prefix:
First Name:JAKWONTEZ
Middle Name:L
Last Name:GLOVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 SOUTH AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1857
Mailing Address - Country:US
Mailing Address - Phone:680-356-3097
Mailing Address - Fax:
Practice Address - Street 1:1403 SOUTH AVE # 1
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-1857
Practice Address - Country:US
Practice Address - Phone:680-356-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker