Provider Demographics
NPI:1922770155
Name:LONG, JUSTIN (LAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5853 SW TERWILLIGER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2860
Mailing Address - Country:US
Mailing Address - Phone:503-515-7191
Mailing Address - Fax:
Practice Address - Street 1:819 SE MORRISON ST STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-6308
Practice Address - Country:US
Practice Address - Phone:503-956-9396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC206937171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist