Provider Demographics
NPI:1548228307
Name:LONG, JODY G (LCSW)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:G
Last Name:LONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N PAULINE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4619
Mailing Address - Country:US
Mailing Address - Phone:901-448-8258
Mailing Address - Fax:901-448-2451
Practice Address - Street 1:1910 NONCONNAH BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2113
Practice Address - Country:US
Practice Address - Phone:901-448-2300
Practice Address - Fax:901-448-6657
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3920189Medicaid
3920184Medicare ID - Type Unspecified