Basic Information
| Provider Information | |||||||||
| NPI: | 1982070959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 OGDEN AVE | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304992404 | ||||||||
| FaxNumber: | 6304992399 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 N EOLA RD | ||||||||
| Address2: | UNIT 110 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605029615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306925660 | ||||||||
| FaxNumber: | 6306925661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2015 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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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 | 163W00000X | 041376253 | IL | N | Nursing Service Providers | Registered Nurse | 363L00000X | 209013052 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.