Provider Demographics
NPI:1891946406
Name:LONG, JESSICA LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6816 W RIO GRANDE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7659
Mailing Address - Country:US
Mailing Address - Phone:509-737-9009
Mailing Address - Fax:509-737-9010
Practice Address - Street 1:6816 W RIO GRANDE AVE STE D
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7659
Practice Address - Country:US
Practice Address - Phone:509-737-9009
Practice Address - Fax:509-737-9010
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WAPY60253462103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid