Healthcare Provider Details

I. General information

NPI: 1568366151
Provider Name (Legal Business Name): JONAH MICHAEL GLOVER CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MAIN ST
SHASTA LAKE CA
96019-9765
US

IV. Provider business mailing address

4701 MAIN ST
SHASTA LAKE CA
96019-9765
US

V. Phone/Fax

Practice location:
  • Phone: 928-297-8471
  • Fax:
Mailing address:
  • Phone: 928-297-8471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number99920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: