Provider Demographics
NPI:1679879621
Name:LONGTIN, JEANNE L (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:L
Last Name:LONGTIN
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N BRADLEY HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-1539
Mailing Address - Country:US
Mailing Address - Phone:989-734-7545
Mailing Address - Fax:989-734-7648
Practice Address - Street 1:555 N BRADLEY HWY
Practice Address - Street 2:SUITE C
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1539
Practice Address - Country:US
Practice Address - Phone:989-734-7545
Practice Address - Fax:989-734-7648
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01138435OtherPROFESSIONAL ASHA NATIONAL LICENSE