Provider Demographics
NPI:1902410160
Name:GLICKMAN, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7344 199TH ST # SR
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1823
Mailing Address - Country:US
Mailing Address - Phone:347-210-1937
Mailing Address - Fax:
Practice Address - Street 1:7344 199TH ST # SR
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1823
Practice Address - Country:US
Practice Address - Phone:347-210-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028608-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist