Basic Information
| Provider Information | |||||||||
| NPI: | 1073015426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 SOMERVILLE RD SE STE 1 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356014309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562607361 | ||||||||
| FaxNumber: | 2563505664 | ||||||||
| Practice Location | |||||||||
| Address1: | 295 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | MOULTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356501210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569746697 | ||||||||
| FaxNumber: | 2563505664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.