Provider Demographics
NPI:1689405524
Name:LONG, JACKIE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 BALBOA PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4962
Mailing Address - Country:US
Mailing Address - Phone:806-440-1663
Mailing Address - Fax:
Practice Address - Street 1:3401 E 30TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8805
Practice Address - Country:US
Practice Address - Phone:505-599-8617
Practice Address - Fax:855-290-2205
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSAH-2024-0179235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist