Provider Demographics
NPI:1073220398
Name:GLICK, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 16TH AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1812
Mailing Address - Country:US
Mailing Address - Phone:347-219-4897
Mailing Address - Fax:
Practice Address - Street 1:5721 16TH AVE
Practice Address - Street 2:APT 2R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204
Practice Address - Country:US
Practice Address - Phone:347-219-4897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst