Provider Demographics
NPI:1528276904
Name:LONGLEY, JEAN V (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:V
Last Name:LONGLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6195 HEARDS CREEK DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3653
Mailing Address - Country:US
Mailing Address - Phone:404-843-3913
Mailing Address - Fax:
Practice Address - Street 1:6195 HEARDS CREEK DR NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3653
Practice Address - Country:US
Practice Address - Phone:404-843-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30640207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15881Medicare UPIN