Provider Demographics
NPI:1821532631
Name:LONG, JACQUE
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 OAK ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-2062
Mailing Address - Country:US
Mailing Address - Phone:541-386-0009
Mailing Address - Fax:
Practice Address - Street 1:315 OAK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2062
Practice Address - Country:US
Practice Address - Phone:541-386-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09396225200000X
WAP160660710225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant