Basic Information
| Provider Information | |||||||||
| NPI: | 1275811408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 CHAPIN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940104062 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 CHAPIN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940104062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503486603 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.