Basic Information
| Provider Information | |||||||||
| NPI: | 1013223130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEEANN | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S 2ND ST | ||||||||
| Address2: | PO BOX 497 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 1009 HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724379622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702379928 | ||||||||
| FaxNumber: | 8702371012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2010 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ATP-000303 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 155123749 | 05 | AR | MEDICAID | 185303758 | 05 | AR | MEDICAID |