Provider Demographics
NPI:1013223130
Name:LONG, JENNIFER LEEANN (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEEANN
Last Name:LONG
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 2ND ST
Mailing Address - Street 2:PO BOX 497
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-2309
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:1009 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:AR
Practice Address - Zip Code:72437-9622
Practice Address - Country:US
Practice Address - Phone:870-237-9928
Practice Address - Fax:870-237-1012
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155123749Medicaid
AR185303758Medicaid
AR185303758Medicaid
AR57297Medicare PIN