Provider Demographics
NPI:1245828730
Name:LONG, JENNIFER D (RMHCI, MCAP, CMHP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:RMHCI, MCAP, CMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12919
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-0919
Mailing Address - Country:US
Mailing Address - Phone:904-472-7233
Mailing Address - Fax:
Practice Address - Street 1:4811 PAYNE STEWART DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-9208
Practice Address - Country:US
Practice Address - Phone:904-472-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCMHP100029101Y00000X
FLIMH20205101YM0800X
101YP1600X
FLMCAP100859101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty