Provider Demographics
NPI:1982070959
Name:LONG, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:2040 OGDEN AVE
Mailing Address - Street 2:SUITE 313
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7206
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-499-2399
Practice Address - Street 1:444 N EOLA RD
Practice Address - Street 2:UNIT 110
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9615
Practice Address - Country:US
Practice Address - Phone:630-692-5660
Practice Address - Fax:630-692-5661
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041376253163W00000X
IL209013052363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse