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General NPI Number Information
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NPI Number | 1174019681
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Entity Type | Organization
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Legal Business Name | DYNAMIC MEDICAL SERVICES PC
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Dates
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Enumeration Date | 07/09/2018
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Last Update Date | 07/09/2018
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Provider Practice Location Address
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Address Line | 25 WILLET AVE
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City | HICKSVILLE
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State | NY
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Zip | 11801-1637
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Country | US
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Telephone | 347-744-8605
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Fax | 516-935-3140
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Provider Business Mailing Address
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Address Line | 25 WILLET AVE
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City | HICKSVILLE
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State | NY
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Zip | 11801-1637
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Country | US
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Telephone | 347-744-8605
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Fax | 516-935-3140
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. GLENN JORSTAD JAKOBSEN
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Credential | DO
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Telephone | 347-744-8605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 197596
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License Number State | NY
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