Provider Demographics
NPI:1669206447
Name:GLUCK, JACOB
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:GLUCK
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 1:501 W CENTRAL AVE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-5688
Mailing Address - Country:US
Mailing Address - Phone:845-662-9847
Mailing Address - Fax:
Practice Address - Street 1:501 W CENTRAL AVE UNIT 102
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5688
Practice Address - Country:US
Practice Address - Phone:845-662-9847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120792104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker