Provider Demographics
NPI:1861918534
Name:LONG, JACK (DPT)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 LIBERTY SQ
Mailing Address - Street 2:BSMT 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5814
Mailing Address - Country:US
Mailing Address - Phone:617-536-1161
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:425 WAVERLEY OAKS RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:781-373-3620
Practice Address - Fax:781-373-3953
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA23177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist