Provider Demographics
NPI:1851332753
Name:JAKOBSEN, GLENN (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:JAKOBSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8371 116TH ST
Mailing Address - Street 2:STE M2
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3448
Mailing Address - Country:US
Mailing Address - Phone:718-441-5700
Mailing Address - Fax:718-441-5337
Practice Address - Street 1:8371 116TH ST
Practice Address - Street 2:STE M2
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3448
Practice Address - Country:US
Practice Address - Phone:718-441-5700
Practice Address - Fax:718-441-5337
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197596208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01817927Medicaid
NY01817927Medicaid
NY03577GMedicare PIN