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General NPI Number Information
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NPI Number | 1790039071
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Entity Type | Individual
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Provider Name | JACKIE LONG M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/07/2012
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 407 3RD ST SE
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City | MINOT
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State | ND
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Zip | 58701-4470
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Country | US
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Telephone | 701-857-2360
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Fax | 701-857-2187
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Provider Business Mailing Address
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Address Line | PO BOX 5010
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City | MINOT
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State | ND
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Zip | 58702-5010
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Country | US
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Telephone | 701-418-8000
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Fax |
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 16459
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME126295
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License Number State | FL
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