Provider Demographics
NPI:1669199170
Name:GLACKIN, JESSE THOMAS JUNG (PLMHP)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:THOMAS JUNG
Last Name:GLACKIN
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 PARKWILD DR APT 127
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-1888
Mailing Address - Country:US
Mailing Address - Phone:712-346-8213
Mailing Address - Fax:
Practice Address - Street 1:5705 W DODGE RD SUITE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6811
Practice Address - Country:US
Practice Address - Phone:402-575-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health