Provider Demographics
NPI:1992198485
Name:LONG, JEANNIE (BCBA)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5958 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-6835
Mailing Address - Country:US
Mailing Address - Phone:520-909-3865
Mailing Address - Fax:
Practice Address - Street 1:1161 N EL DORADO PL # 103
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4607
Practice Address - Country:US
Practice Address - Phone:520-748-7108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ158008Medicaid