Provider Demographics
NPI:1881240349
Name:LONG, JERRY LEE JR
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:LONG
Suffix:JR
Gender:M
Credentials:
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 34086
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-0086
Mailing Address - Country:US
Mailing Address - Phone:813-494-1282
Mailing Address - Fax:
Practice Address - Street 1:6654 BITTEROOT LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-1451
Practice Address - Country:US
Practice Address - Phone:813-494-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment