Provider Demographics
NPI:1831458561
Name:LONG, JEREMY DE WAYNE (LMHC, LPC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DE WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 TEJON AVE SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-7437
Mailing Address - Country:US
Mailing Address - Phone:321-482-9492
Mailing Address - Fax:
Practice Address - Street 1:870 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7418
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 11075101YM0800X
WI5617-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100057489Medicaid