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General NPI Number Information
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NPI Number | 1366480949
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Entity Type | Individual
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Provider Name | JACK E LONG MD
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Gender | Male
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 02/27/2008
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Provider Practice Location Address
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Address Line | 100 E 33RD ST STE 100
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City | VANCOUVER
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State | WA
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Zip | 98663-2776
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Country | US
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Telephone | 360-256-2000
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Fax | 360-514-7553
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Provider Business Mailing Address
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Address Line | PO BOX 1600
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City | VANCOUVER
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State | WA
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Zip | 98668-1600
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Country | US
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Telephone | 360-514-7550
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Fax | 360-514-7553
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD00028913
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | MD00028913
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License Number State | WA
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