Healthcare Provider Details

I. General information

NPI: 1730259821
Provider Name (Legal Business Name): JONATHAN W. GLENN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 5TH AVE SW
MAGEE MS
39111-3960
US

IV. Provider business mailing address

PO BOX 969
MAGEE MS
39111-0969
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-4070
  • Fax: 601-849-4055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1089
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: