Provider Demographics
NPI:1184792129
Name:LONG, JACK A (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 E GREEN CANYON DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9105
Mailing Address - Country:US
Mailing Address - Phone:208-850-6511
Mailing Address - Fax:208-888-3882
Practice Address - Street 1:2893 E GREEN CANYON DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9105
Practice Address - Country:US
Practice Address - Phone:208-850-6511
Practice Address - Fax:208-888-3882
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025046Medicaid
ID1670956Medicare ID - Type UnspecifiedCHIROPRACTIC PROVIDER