Provider Demographics
NPI:1508241506
Name:LONGO, JENELLE C (APRN)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:C
Last Name:LONGO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:C
Other - Last Name:VARGULICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:1325 SAN MARCO BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8566
Practice Address - Country:US
Practice Address - Phone:904-346-3465
Practice Address - Fax:904-396-0388
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339731-1363LF0000X
FLAPRN9413215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017401700Medicaid