Provider Demographics
NPI:1376839506
Name:LONGO, JENNIFER E (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:LONGO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-2405
Mailing Address - Country:US
Mailing Address - Phone:330-386-2054
Mailing Address - Fax:330-386-2679
Practice Address - Street 1:425 W 5TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2405
Practice Address - Country:US
Practice Address - Phone:330-386-2054
Practice Address - Fax:330-386-2679
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013257225100000X
OHPT013257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2577162Medicaid
OH2577162Medicaid