Provider Demographics
NPI:1356699458
Name:LONG, JONILLA DEANE
Entity type:Individual
Prefix:
First Name:JONILLA
Middle Name:DEANE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 SANTA FE ST
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-3905
Mailing Address - Country:US
Mailing Address - Phone:580-737-0323
Mailing Address - Fax:
Practice Address - Street 1:1095 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1252
Practice Address - Country:US
Practice Address - Phone:580-824-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23592171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator