Provider Demographics
NPI:1992575351
Name:GLICK, JESSICA LYNN (RPH)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:GLICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:MODLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2 WATERSEDGE CT
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-1126
Mailing Address - Country:US
Mailing Address - Phone:516-724-0886
Mailing Address - Fax:
Practice Address - Street 1:254 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2201
Practice Address - Country:US
Practice Address - Phone:516-739-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0412861835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care