=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841720547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST COUNSELING AND ASSESSMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 WASHINGTON AVE STE 107
-----------------------------------------------------
City | WEST PLAINS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65775-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-255-8790
-----------------------------------------------------
Fax | 417-222-6991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 WASHINGTON AVE STE 107
-----------------------------------------------------
City | WEST PLAINS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65775-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-255-8790
-----------------------------------------------------
Fax | 417-222-6991
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JENNIFER LONG
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 417-425-2565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2010030531
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------