Provider Demographics
NPI:1154540714
Name:LONG, JAI (LMFT111561)
Entity type:Individual
Prefix:MR
First Name:JAI
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:LMFT111561
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401
Mailing Address - Country:US
Mailing Address - Phone:310-576-1308
Mailing Address - Fax:310-576-1027
Practice Address - Street 1:3435 OCEAN PARK BLVD.
Practice Address - Street 2:#207
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405
Practice Address - Country:US
Practice Address - Phone:310-392-9474
Practice Address - Fax:323-294-7261
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75042106H00000X
CALMFT111561106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist