Provider Demographics
NPI:1508568692
Name:LONG, BRENDA JO (CHW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JO
Last Name:LONG
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3391
Mailing Address - Country:US
Mailing Address - Phone:320-335-5257
Mailing Address - Fax:
Practice Address - Street 1:3905 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3391
Practice Address - Country:US
Practice Address - Phone:320-335-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker