Provider Demographics
NPI:1144599572
Name:DR. JACK M. LONG & ASSOC., P.A.
Entity Type:Organization
Organization Name:DR. JACK M. LONG & ASSOC., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-744-5499
Mailing Address - Street 1:720 MAIDEN CHOICE LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5940
Mailing Address - Country:US
Mailing Address - Phone:410-744-5499
Mailing Address - Fax:410-455-0894
Practice Address - Street 1:720 MAIDEN CHOICE LN
Practice Address - Street 2:SUITE C
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5940
Practice Address - Country:US
Practice Address - Phone:410-744-5499
Practice Address - Fax:410-455-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD030681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ292JMOtherMEDICARE UNSPECIFIED
MDR7610001OtherBCBS FEDERAL
MD755011100OtherMAMSI
MD755011100Medicaid
MDR7610001OtherBLUE CHOICE