Provider Demographics
NPI:1336189893
Name:GLICK, JAN S (CCC-A)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:S
Last Name:GLICK
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PLANTATION RIDGE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9175
Mailing Address - Country:US
Mailing Address - Phone:704-230-0007
Mailing Address - Fax:
Practice Address - Street 1:514 E WOOLBRIGHT RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-6033
Practice Address - Country:US
Practice Address - Phone:561-434-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000072231H00000X
OHA01525231H00000X
FLAY1405231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI904547880Medicaid
MI804700455Medicaid