Provider Demographics
NPI:1851738900
Name:LONG, JEANNA MICHELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 S BENEVA RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-2411
Mailing Address - Country:US
Mailing Address - Phone:941-953-9612
Mailing Address - Fax:941-953-9612
Practice Address - Street 1:743 S BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-2411
Practice Address - Country:US
Practice Address - Phone:941-953-9612
Practice Address - Fax:941-953-9612
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10991310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility