Provider Demographics
NPI:1366480949
Name:LONG, JACK E (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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 1600
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1600
Mailing Address - Country:US
Mailing Address - Phone:360-514-7550
Mailing Address - Fax:360-514-7553
Practice Address - Street 1:100 E 33RD ST STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2776
Practice Address - Country:US
Practice Address - Phone:360-256-2000
Practice Address - Fax:360-514-7553
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028913207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8131195Medicaid
WA8131195Medicaid