Provider Demographics
NPI:1558639294
Name:LONG, JODY (NP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2901
Mailing Address - Country:US
Mailing Address - Phone:219-836-1600
Mailing Address - Fax:
Practice Address - Street 1:1444 S POTOMAC ST STE 200
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4509
Practice Address - Country:US
Practice Address - Phone:303-226-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28144376A363LF0000X
CO993239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily