Provider Demographics
NPI:1083335285
Name:LONG, JACOB (MA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 GENE HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-9072
Mailing Address - Country:US
Mailing Address - Phone:336-553-8147
Mailing Address - Fax:336-464-2376
Practice Address - Street 1:149 GENE HILL RD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-9072
Practice Address - Country:US
Practice Address - Phone:336-553-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA18420101YP2500X
VA0704005653101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional