Provider Demographics
NPI:1407269160
Name:LONG, JACOB GLENN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GLENN
Last Name:LONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1350 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5112
Mailing Address - Country:US
Mailing Address - Phone:601-981-2611
Mailing Address - Fax:
Practice Address - Street 1:5830 CORAL RIDGE DR STE 120
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3388
Practice Address - Country:US
Practice Address - Phone:866-425-5768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14764225100000X
MSPT5387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist