Provider Demographics
NPI:1477114213
Name:LONG, JALESA SYMONE (CRNP)
Entity Type:Individual
Prefix:
First Name:JALESA
Middle Name:SYMONE
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35218-1638
Mailing Address - Country:US
Mailing Address - Phone:256-460-8109
Mailing Address - Fax:205-788-4767
Practice Address - Street 1:2010 AVENUE F
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35218-1638
Practice Address - Country:US
Practice Address - Phone:256-460-8109
Practice Address - Fax:205-788-4767
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-138748363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner