Provider Demographics
NPI:1902072036
Name:LONG, JENNIFER V (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:V
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1571
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1571
Mailing Address - Country:US
Mailing Address - Phone:301-723-4965
Mailing Address - Fax:301-723-4983
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:240-964-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR141065163WM0705X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical