Healthcare Provider Details

I. General information

NPI: 1437605177
Provider Name (Legal Business Name): JENIFER LONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DRIVE SOUTH SUITE 201A
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DRIVE SOUTH SUITE 201A
ST AUGUSTINE FL
32080
US

V. Phone/Fax

Practice location:
  • Phone: 904-770-7685
  • Fax:
Mailing address:
  • Phone: 904-770-7685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13814
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: