Provider Demographics
NPI:1194244707
Name:LONG, JESSICA BETH (AGNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:LONG
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BETH
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:420 E STATE ST STE 135
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4898
Mailing Address - Country:US
Mailing Address - Phone:208-402-9956
Mailing Address - Fax:
Practice Address - Street 1:420 E STATE ST STE 135
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4898
Practice Address - Country:US
Practice Address - Phone:208-402-9956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56895363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner