Provider Demographics
NPI:1114643178
Name:LONG, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
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 1:1203 1ST ST STE 505
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3034
Mailing Address - Country:US
Mailing Address - Phone:517-227-3700
Mailing Address - Fax:888-323-2176
Practice Address - Street 1:1203 1ST ST STE 505
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3034
Practice Address - Country:US
Practice Address - Phone:517-227-3700
Practice Address - Fax:888-323-2176
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171000000XOther Service ProvidersMilitary Health Care Provider
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist