Provider Demographics
NPI:1891221792
Name:LONG, JENNIFER MILDRED (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MILDRED
Last Name:LONG
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 BEVIS LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-9720
Mailing Address - Country:US
Mailing Address - Phone:704-902-5512
Mailing Address - Fax:
Practice Address - Street 1:1165 MCKEE FARM LN
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-8671
Practice Address - Country:US
Practice Address - Phone:704-928-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0107341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical