Basic Information
| Provider Information | |||||||||
| NPI: | 1487032827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JACKSON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 COPPERFIELD BLVD NE STE 202 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047212060 | ||||||||
| FaxNumber: | 7047892090 | ||||||||
| Practice Location | |||||||||
| Address1: | 8560 COOK ST | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281247686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044366521 | ||||||||
| FaxNumber: | 7044369505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 210563 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.