Provider Demographics
NPI:1104692797
Name:LONG, JENIFER (MSPT)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 IRVINE RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-7409
Mailing Address - Country:US
Mailing Address - Phone:703-431-4939
Mailing Address - Fax:
Practice Address - Street 1:175 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-9591
Practice Address - Country:US
Practice Address - Phone:859-745-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist