Provider Demographics
NPI:1184006934
Name:LONG, JENNIFER LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 SHANDON DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-7769
Mailing Address - Country:US
Mailing Address - Phone:513-616-2243
Mailing Address - Fax:
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-461-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-28
Last Update Date:2015-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.361446163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse