Provider Demographics
NPI:1720121619
Name:LONG, DOUGLAS JESS (MS ES LAT ATC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JESS
Last Name:LONG
Suffix:
Gender:M
Credentials:MS ES LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6108
Mailing Address - Country:US
Mailing Address - Phone:308-696-7456
Mailing Address - Fax:308-696-8637
Practice Address - Street 1:1115 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6108
Practice Address - Country:US
Practice Address - Phone:308-696-7456
Practice Address - Fax:308-696-8637
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer