Basic Information
| Provider Information | |||||||||
| NPI: | 1962463984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGSHAW | ||||||||
| FirstName: | JACQUELYNN | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 867 WINDY MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751157551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722301754 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2828 DUKE OF GLOUCESTER ST | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722983888 | ||||||||
| FaxNumber: | 9722960838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | K2061 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.