Provider Demographics
NPI:1851351589
Name:GLICK, JILL E (DO)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:GLICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 ED HALL DR STE B-108
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-1861
Mailing Address - Country:US
Mailing Address - Phone:972-932-5555
Mailing Address - Fax:972-932-5557
Practice Address - Street 1:874 ED HALL DR STE B-108
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-1861
Practice Address - Country:US
Practice Address - Phone:972-932-5555
Practice Address - Fax:972-932-5557
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149817202Medicaid
TX8L9889Medicare PIN
TX149817202Medicaid