Healthcare Provider Details

I. General information

NPI: 1891042149
Provider Name (Legal Business Name): JENNIFER GLOVER CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 N FREMONT BLVD
FLAGSTAFF AZ
86001-0955
US

IV. Provider business mailing address

2124 N FREMONT BLVD
FLAGSTAFF AZ
86001-0955
US

V. Phone/Fax

Practice location:
  • Phone: 602-909-5524
  • Fax:
Mailing address:
  • Phone: 602-909-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number0007543
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number0117006530
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberTT14906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: