Individual
DENNIS LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
1850 CHADWICK DR, JACKSON, MS 39204-3404
(904) 805-1300
(904) 805-1302
Mailing address
PO BOX 75473, BALTIMORE, MD 21275-5473
(904) 805-1300
(904) 805-1302
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
R851248
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00123788
—
MS
01
—
202011213A
BLUE CROSS
MS
01
—
P00212593
RAILROAD MEDICARE
MS
Enumeration date
06/15/2006
Last updated
02/23/2015
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