Provider Demographics
NPI:1578837670
Name:LONG, JACQUELINE A
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:ANNE
Other - Last Name:DOWLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:311 WEST FAIRCHILD STREET
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61837-3876
Practice Address - Country:US
Practice Address - Phone:217-431-7700
Practice Address - Fax:217-431-7850
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270641Medicare PIN