Provider Demographics
NPI:1659629830
Name:LONG, JENNIFER NICOLE (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:LONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 S ALAFAYA TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8926
Mailing Address - Country:US
Mailing Address - Phone:407-454-1514
Mailing Address - Fax:
Practice Address - Street 1:1525 S ALAFAYA TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8926
Practice Address - Country:US
Practice Address - Phone:407-454-1514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 27657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist