Healthcare Provider Details

I. General information

NPI: 1831334952
Provider Name (Legal Business Name): JENNIFER ANN LONG MA, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 FROST AVENUE SENIOR RECOVERY PROGRAM
ST. PAUL MN
55109
US

IV. Provider business mailing address

1351 FROST AVENUE SENIOR RECOVERY PROGRAM
ST. PAUL MN
55109
US

V. Phone/Fax

Practice location:
  • Phone: 651-773-0473
  • Fax: 651-773-9298
Mailing address:
  • Phone: 651-773-0473
  • Fax: 651-773-9298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301686
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: