Healthcare Provider Details

I. General information

NPI: 1255606158
Provider Name (Legal Business Name): JENNIFER L GLOCK PSYCHOLOGICAL CONSULTING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 SAN JOSE PL STE 1
JACKSONVILLE FL
32257-8867
US

IV. Provider business mailing address

10232 SAN JOSE BLVD
JACKSONVILLE FL
32257-6203
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-0218
  • Fax: 904-880-0802
Mailing address:
  • Phone: 904-260-0218
  • Fax: 904-292-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT604
License Number StateFL

VIII. Authorized Official

Name: JENNIFER GLOCK
Title or Position: OWNER
Credential: MA
Phone: 904-260-0218