Healthcare Provider Details

I. General information

NPI: 1609495282
Provider Name (Legal Business Name): AJASHA MAXINE LONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2591
JACKSONVILLE FL
32258-7420
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax: 904-390-7405
Mailing address:
  • Phone: 314-780-8699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY12271
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP.08309
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: