MEDICARE: JILLYAN AVERY LONG PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	3281	OK

General Provider Information

NPI Number	:	1548854557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLYAN AVERY LONG PTA

Provider Business Mailing Address
First Line	:	8165 S MINGO RD STE 101
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-4667
Country	:	US
Telephone Number	:	918-615-6280
Fax Number	:	918-615-6240

Provider Business Practice Location Address
First Line	:	8165 S MINGO RD STE 101
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-4667
Country	:	US
Telephone Number	:	918-615-6280
Fax Number	:	918-615-6240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2021
Last Update Date	:	02/18/2026

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