MEDICARE: DR. JENNIFER SUZANNE LONG PSYD

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	103TC0700X	Clinical Psychologist	2010030531	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639280688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER SUZANNE LONG PSYD

Provider Business Mailing Address
First Line	:	408 WASHINGTON AVE
Second Line	:	STE 107
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-3404
Country	:	US
Telephone Number	:	417-255-8790
Fax Number	:	417-222-6991

Provider Business Practice Location Address
First Line	:	408 WASHINGTON AVE
Second Line	:	STE 107
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-3404
Country	:	US
Telephone Number	:	417-255-8790
Fax Number	:	417-222-6991

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	06/28/2017

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