Provider Demographics
NPI:1841548450
Name:LONGDEN, JEAN MARIE
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:LONGDEN
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 1:5 FRUITWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAY
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-453-7633
Mailing Address - Fax:315-637-4477
Practice Address - Street 1:5 FRUITWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MAY
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-453-7633
Practice Address - Fax:315-637-4477
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20988-1146D00000X, 251J00000X, 251S00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No251S00000XAgenciesCommunity/Behavioral Health
No302R00000XManaged Care OrganizationsHealth Maintenance Organization