Provider Demographics
NPI:1164904710
Name:LONG, JEANNIE
Entity Type:Individual
Prefix:
First Name:JEANNIE
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:PO BOX 135
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-0135
Mailing Address - Country:US
Mailing Address - Phone:580-824-0676
Mailing Address - Fax:
Practice Address - Street 1:1095 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1252
Practice Address - Country:US
Practice Address - Phone:580-824-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist