Provider Demographics
NPI:1174771992
Name:GLICK, JENNIFER K (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:GLICK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2687 OAK RD UNIT 260
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-7888
Mailing Address - Country:US
Mailing Address - Phone:310-975-9375
Mailing Address - Fax:
Practice Address - Street 1:2687 OAK RD UNIT 260
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-7888
Practice Address - Country:US
Practice Address - Phone:650-980-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62755106H00000X
225400000X
CALMFT88575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL SECURITY NUMBER