Provider Demographics
NPI:1609024140
Name:LONGENECKER, JEFFREY NEIL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:NEIL
Last Name:LONGENECKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:TN
Mailing Address - Zip Code:37353-4069
Mailing Address - Country:US
Mailing Address - Phone:615-829-3949
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-744-3308
Practice Address - Fax:423-744-3495
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1655363A00000X, 363AM0700X
TN363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665294Medicaid
TN4204068OtherBCBS
TN4204066OtherBSBS
D33491Medicare UPIN
TN0922510001Medicare NSC
3665294Medicare PIN