Provider Demographics
NPI:1730733460
Name:LONG, JENNIFER DAWN (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:LONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 E KLEES RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 N STATE ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-8749
Practice Address - Country:US
Practice Address - Phone:616-821-5266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008361225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist