Provider Demographics
NPI:1215595178
Name:LONG, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:524 ST AUGUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-2154
Mailing Address - Country:US
Mailing Address - Phone:541-531-2151
Mailing Address - Fax:541-249-4100
Practice Address - Street 1:3132 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8688
Practice Address - Country:US
Practice Address - Phone:541-414-0503
Practice Address - Fax:541-141-0504
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC192417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist