Provider Demographics
NPI:1881146769
Name:GLICK, JEFFREY R
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:GLICK
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 1:10735 S CICERO AVE
Mailing Address - Street 2:208
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5400
Mailing Address - Country:US
Mailing Address - Phone:708-424-0001
Mailing Address - Fax:
Practice Address - Street 1:10735 S CICERO AVE
Practice Address - Street 2:SUITE # 208
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5400
Practice Address - Country:US
Practice Address - Phone:708-424-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011516101YP2500X
IL180.012972101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional