Provider Demographics
NPI:1790039071
Name:LONG, JACKIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-418-8000
Mailing Address - Fax:
Practice Address - Street 1:407 3RD ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4470
Practice Address - Country:US
Practice Address - Phone:701-857-2360
Practice Address - Fax:701-857-2187
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1262952084P0800X
ND164592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME126295OtherSTATE LICENSE