Healthcare Provider Details

I. General information

NPI: 1982593604
Provider Name (Legal Business Name): JENNA CLAIRE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 HORSESHOE DR
SANTA ROSA CA
95405-8139
US

IV. Provider business mailing address

5555 RIO VIDA LN
SEBASTOPOL CA
95472-2006
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-4433
  • Fax:
Mailing address:
  • Phone: 510-866-4170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: