Provider Demographics
NPI:1295375293
Name:GLASS, JACKIE JOY
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:JOY
Last Name:GLASS
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 1:2901 W CYPRESS CREEK RD STE 123124
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1730
Mailing Address - Country:US
Mailing Address - Phone:954-915-7444
Mailing Address - Fax:
Practice Address - Street 1:2901 W CYPRESS CREEK RD STE 123124
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1730
Practice Address - Country:US
Practice Address - Phone:954-915-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor