MEDICARE: JESAIRA LESHONDA GLOVER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC012474	GA
2	101YP2500X	Professional Counselor	LPC012474	GA
3	101YM0800X	Mental Health Counselor	LPC012474	GA

General Provider Information

NPI Number	:	1629731849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESAIRA LESHONDA GLOVER LPC

Provider Business Mailing Address
First Line	:	6909 ROSWELL RD APT J
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-2310
Country	:	US
Telephone Number	:	470-309-2703
Fax Number	:

Provider Business Practice Location Address
First Line	:	6909 ROSWELL RD APT J
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-2310
Country	:	US
Telephone Number	:	470-309-2703
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2021
Last Update Date	:	10/14/2021

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