Individual
JACKIE LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S. CCC-SLP
Contact information
Practice address
3401 E 30TH ST, FARMINGTON, NM 87402-8805
(505) 599-8617
(855) 290-2205
Mailing address
4623 BALBOA PARK LOOP, BRADENTON, FL 34211-4962
(806) 440-1663
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SAH-2024-0179
NM
Other
Enumeration date
08/12/2024
Last updated
08/12/2024
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