Provider Demographics
NPI:1174019681
Name:DYNAMIC MEDICAL SERVICES PC
Entity type:Organization
Organization Name:DYNAMIC MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:JORSTAD
Authorized Official - Last Name:JAKOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:347-744-8605
Mailing Address - Street 1:25 WILLET AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-1637
Mailing Address - Country:US
Mailing Address - Phone:347-744-8605
Mailing Address - Fax:516-935-3140
Practice Address - Street 1:25 WILLET AVE
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1637
Practice Address - Country:US
Practice Address - Phone:347-744-8605
Practice Address - Fax:516-935-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197596208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty