Provider Demographics
NPI:1861903841
Name:LONG, JENNA-ANN LORRAINE
Entity type:Individual
Prefix:
First Name:JENNA-ANN
Middle Name:LORRAINE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 ESSEX LN APT 7305
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-8124
Mailing Address - Country:US
Mailing Address - Phone:919-904-2427
Mailing Address - Fax:
Practice Address - Street 1:4000 ESSEX LN APT 7305
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-8124
Practice Address - Country:US
Practice Address - Phone:919-904-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0129231041C0700X
TX1033871041C0700X
NCP0119931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103387OtherLCSW
NCC012923OtherLCSW