Provider Demographics
NPI:1174696462
Name:LONG, JAN P (MSN ANP-C)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:P
Last Name:LONG
Suffix:
Gender:F
Credentials:MSN ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:545 BECKETT RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LOGAN TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1547
Mailing Address - Country:US
Mailing Address - Phone:856-467-2556
Mailing Address - Fax:856-467-3816
Practice Address - Street 1:545 BECKETT RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LOGAN TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08085-1547
Practice Address - Country:US
Practice Address - Phone:856-467-2556
Practice Address - Fax:856-467-3816
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10757100363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P40506Medicare UPIN
NV051102XVAMedicare UPIN