Provider Demographics
NPI:1386943694
Name:GLOCK, JACOB LEON (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LEON
Last Name:GLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15730 NEW HAMPSHIRE CT
Mailing Address - Street 2:UNIT 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4121
Mailing Address - Country:US
Mailing Address - Phone:239-561-3430
Mailing Address - Fax:239-561-6980
Practice Address - Street 1:15730 NEW HAMPSHIRE CT
Practice Address - Street 2:UNIT 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4121
Practice Address - Country:US
Practice Address - Phone:239-561-3430
Practice Address - Fax:239-561-6980
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379285400Medicaid