Provider Demographics
NPI:1861058901
Name:LONG, JANE CRITZ (RD, LD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:CRITZ
Last Name:LONG
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:CRITZ
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:840 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-3227
Mailing Address - Country:US
Mailing Address - Phone:662-756-1649
Mailing Address - Fax:662-756-4114
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-1649
Practice Address - Fax:662-756-4114
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1322133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered