Provider Demographics
NPI:1386466431
Name:GLEN, JACOB STEWART (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:STEWART
Last Name:GLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 BRETT RD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-3304
Mailing Address - Country:US
Mailing Address - Phone:804-516-2450
Mailing Address - Fax:
Practice Address - Street 1:975 AIRPORT RD SW STE H
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1395
Practice Address - Country:US
Practice Address - Phone:256-203-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2877111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor