Provider Demographics
NPI:1922363068
Name:LONGO, JENNIFFER A (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFFER
Middle Name:A
Last Name:LONGO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFFER
Other - Middle Name:A
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:410 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2680
Mailing Address - Country:US
Mailing Address - Phone:406-751-8331
Mailing Address - Fax:
Practice Address - Street 1:410 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-751-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT372071041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA3419OtherSTATE OF OREGON STATE BOARD OF LICENSED SOCIAL WORKERS