Provider Demographics
NPI:1669657748
Name:LONG, JENNIFER LYNN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA SUITE 550
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6975
Practice Address - Country:US
Practice Address - Phone:310-206-6688
Practice Address - Fax:310-825-2810
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA93108207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology