Healthcare Provider Details

I. General information

NPI: 1548359193
Provider Name (Legal Business Name): JO ANN LONGENECKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2673 DAVISSON RUN RD STE 101
CLARKSBURG WV
26301-6838
US

IV. Provider business mailing address

2324 HAWK HIGHWAY
LOST CREEK WV
26385-9707
US

V. Phone/Fax

Practice location:
  • Phone: 681-342-3470
  • Fax: 304-622-6109
Mailing address:
  • Phone: 304-745-3200
  • Fax: 304-745-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15551
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: