Healthcare Provider Details

I. General information

NPI: 1477361251
Provider Name (Legal Business Name): JORDAN GLOVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16538 N MAY AVE
EDMOND OK
73012-9007
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 405-265-9208
  • Fax:
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-393204
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: