MEDICARE: JAMIE LONG CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	COA.18885-NP	OH

General Provider Information

NPI Number	:	1215399027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE LONG CNP

Provider Business Mailing Address
First Line	:	7700 WASHINGTON VILLAGE DR
Second Line	:	SUITE 220
City	:	DAYTON
State	:	OH
Zip	:	45459-4094
Country	:	US
Telephone Number	:	937-438-0009
Fax Number	:	937-438-0902

Provider Business Practice Location Address
First Line	:	7700 WASHINGTON VILLAGE DR
Second Line	:	SUITE 230
City	:	DAYTON
State	:	OH
Zip	:	45459-4094
Country	:	US
Telephone Number	:	937-438-0009
Fax Number	:	937-438-0902

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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