Provider Demographics
NPI:1245306968
Name:LONG, JALETTA L (RN MN CFNP)
Entity type:Individual
Prefix:
First Name:JALETTA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:RN MN CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30302-4019
Mailing Address - Country:US
Mailing Address - Phone:404-413-1191
Mailing Address - Fax:404-413-1191
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN060596208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000864366AMedicaid