Provider Demographics
NPI:1023395225
Name:LONGNECKER, LAURA JILL
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JILL
Last Name:LONGNECKER
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:RR 1 BOX 83D
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:IL
Mailing Address - Zip Code:62047-9609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1316 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-3617
Practice Address - Country:US
Practice Address - Phone:618-498-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist