Provider Demographics
NPI:1356559389
Name:GLAZE, HENRY M JR (JD, LMFT)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:M
Last Name:GLAZE
Suffix:JR
Gender:M
Credentials:JD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2168
Mailing Address - Country:US
Mailing Address - Phone:601-948-4475
Mailing Address - Fax:
Practice Address - Street 1:643 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3304
Practice Address - Country:US
Practice Address - Phone:601-948-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0143106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist