Provider Demographics
NPI:1013590058
Name:LONG, JACQUELINE JOYCE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JOYCE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HIGGINSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64037-1607
Mailing Address - Country:US
Mailing Address - Phone:816-810-0935
Mailing Address - Fax:
Practice Address - Street 1:214 FERREL ST
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9511
Practice Address - Country:US
Practice Address - Phone:816-469-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician