Provider Demographics
NPI:1184742009
Name:GLICKMAN, JAY HOWARD (LPCC)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:HOWARD
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8367
Practice Address - Street 1:301 W COLLEGE AVE
Practice Address - Street 2:HMS SILVER CITY MENTAL HEALTH CENTER
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061
Practice Address - Country:US
Practice Address - Phone:575-313-8222
Practice Address - Fax:575-542-8367
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0103521101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24785806Medicaid