Basic Information
| Provider Information | |||||||||
| NPI: | 1538618400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JACQUELYNN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4530 E SHEA BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022644834 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4530 E SHEA BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022644834 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2016 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | DA10110 | AZ | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | DA10110 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.