Provider Demographics
NPI:1639280688
Name:LONG, JENNIFER SUZANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:SUZANNE
Other - Last Name:CROWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:408 WASHINGTON AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-3404
Mailing Address - Country:US
Mailing Address - Phone:417-255-8790
Mailing Address - Fax:417-222-6991
Practice Address - Street 1:408 WASHINGTON AVE
Practice Address - Street 2:STE 107
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3404
Practice Address - Country:US
Practice Address - Phone:417-255-8790
Practice Address - Fax:417-222-6991
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010030531103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497555003Medicaid