Provider Demographics
NPI:1710329156
Name:LONG, JACOB DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ACORN LN
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2359
Mailing Address - Country:US
Mailing Address - Phone:662-609-6402
Mailing Address - Fax:
Practice Address - Street 1:2202 HWY 82 WEST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2706
Practice Address - Country:US
Practice Address - Phone:662-609-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist