Provider Demographics
NPI:1962463984
Name:LONGSHAW, JACQUELYNN ANTOINETTE (MD)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYNN
Middle Name:ANTOINETTE
Last Name:LONGSHAW
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:867 WINDY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-7551
Mailing Address - Country:US
Mailing Address - Phone:972-230-1754
Mailing Address - Fax:
Practice Address - Street 1:2828 DUKE OF GLOUCESTER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2067
Practice Address - Country:US
Practice Address - Phone:972-298-3888
Practice Address - Fax:972-296-0838
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK2061208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS89940Medicare UPIN