Provider Demographics
NPI:1962685487
Name:LONG, JENNIFER (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2920 MCINTYRE DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4221
Mailing Address - Country:US
Mailing Address - Phone:812-336-4947
Mailing Address - Fax:812-336-3661
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 305
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-336-4947
Practice Address - Fax:812-336-3661
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71001198A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP28485Medicare UPIN
IN548850FMedicare PIN