Provider Demographics
NPI:1447296629
Name:LONG, JACK MARTIN (PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:MARTIN
Last Name:LONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 MAIDEN CHOICE LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5940
Mailing Address - Country:US
Mailing Address - Phone:410-744-5499
Mailing Address - Fax:410-455-0894
Practice Address - Street 1:720C MAIDEN CHOICE LN
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5940
Practice Address - Country:US
Practice Address - Phone:410-744-5499
Practice Address - Fax:410-455-0894
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD030681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD755011100Medicaid
MDR7610001OtherBC/BS FEDERAL
MDQ292JMOtherBLUE CROSS/ BLUE SHIELD
MDR7610001OtherBLUE CHOICE
MD276629OtherMAMSI
MD276629OtherMAMSI