Provider Demographics
NPI:1073271078
Name:LONG, JANIKA
Entity Type:Individual
Prefix:
First Name:JANIKA
Middle Name:
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 1:350 CITY VIEW DR STE 206
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5326
Mailing Address - Country:US
Mailing Address - Phone:307-789-7915
Mailing Address - Fax:307-789-6009
Practice Address - Street 1:350 CITY VIEW DR STE 206
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5326
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:307-789-6009
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
WYLCSW-11361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist