Provider Demographics
NPI:1013138957
Name:LONG, JEANINE (LCPC)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 1ST ST N APT 206
Mailing Address - Street 2:SUITE A
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4905
Mailing Address - Country:US
Mailing Address - Phone:316-259-7018
Mailing Address - Fax:316-686-0036
Practice Address - Street 1:4601 E DOUGLAS AVE STE 120
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1032
Practice Address - Country:US
Practice Address - Phone:316-535-9894
Practice Address - Fax:316-337-5530
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health