Provider Demographics
NPI:1194222398
Name:GLICK, JESSE (PA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 RUN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CONESTOGA
Mailing Address - State:PA
Mailing Address - Zip Code:17516-9734
Mailing Address - Country:US
Mailing Address - Phone:717-723-0147
Mailing Address - Fax:
Practice Address - Street 1:86 RUN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CONESTOGA
Practice Address - State:PA
Practice Address - Zip Code:17516-9734
Practice Address - Country:US
Practice Address - Phone:717-723-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant