Provider Demographics
NPI:1053047753
Name:LONG, JONATHAN BRAXTON (LCSW-A)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRAXTON
Last Name:LONG
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4429 IYAR WAY
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4167
Mailing Address - Country:US
Mailing Address - Phone:252-532-1320
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1838
Practice Address - Country:US
Practice Address - Phone:980-237-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0166571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical