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General NPI Number Information
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NPI Number | 1992866057
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Entity Type | Individual
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Provider Name | JACQLYN E LONG O.D.
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Gender | Female
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 211 E BROADWAY
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City | ALTON
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State | IL
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Zip | 62002-6220
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Country | US
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Telephone | 618-462-9818
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Fax | 314-741-4947
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Provider Business Mailing Address
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Address Line | 8885 LADUE RD
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City | SAINT LOUIS
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State | MO
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Zip | 63124-2088
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Country | US
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Telephone | 314-721-2720
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Fax | 314-725-2685
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T02865
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-008207
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License Number State | IL
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