Healthcare Provider Details

I. General information

NPI: 1598829970
Provider Name (Legal Business Name): JACQLYN E. LONG, OD, & ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 TELEGRAPH RD STE 119
SAINT LOUIS MO
63129-3500
US

IV. Provider business mailing address

5445 TELEGRAPH RD STE 119
SAINT LOUIS MO
63129-3500
US

V. Phone/Fax

Practice location:
  • Phone: 314-845-0770
  • Fax: 314-845-0814
Mailing address:
  • Phone: 314-845-0770
  • Fax: 314-845-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQLYN E. LONG
Title or Position: PRESIDENT
Credential: O.D.
Phone: 314-845-0770