Provider Demographics
NPI:1821010356
Name:LONG, JACKIE D (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JACKIE
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:390 NE MIDWAY BLVD
Mailing Address - Street 2:#B-101
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-2642
Mailing Address - Country:US
Mailing Address - Phone:360-679-4211
Mailing Address - Fax:360-279-2545
Practice Address - Street 1:390 NE MIDWAY BLVD
Practice Address - Street 2:#B-101
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-2642
Practice Address - Country:US
Practice Address - Phone:360-679-4211
Practice Address - Fax:360-279-2545
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WALL00003493235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist