Provider Demographics
NPI:1932284700
Name:LONG, JEFFERY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3664
Mailing Address - Country:US
Mailing Address - Phone:815-937-2284
Mailing Address - Fax:
Practice Address - Street 1:692 N. MAPLE
Practice Address - Street 2:
Practice Address - City:HERSCHER
Practice Address - State:IL
Practice Address - Zip Code:60941
Practice Address - Country:US
Practice Address - Phone:815-426-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE23458Medicare UPIN