Individual
TIA JACQUELINE LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S.
Contact information
Practice address
6333 ODANA RD, MADISON, WI 53719-1170
(608) 270-2511
Mailing address
607 4TH ST, BRODHEAD, WI 53520-1135
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
—
—
106H00000X
Marriage & Family Therapist
Primary
—
—
Other
Enumeration date
05/20/2013
Last updated
05/20/2013
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