Provider Demographics
NPI:1376132423
Name:LONG, JESSICA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
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 810
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-0810
Mailing Address - Country:US
Mailing Address - Phone:603-308-1467
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant