Provider Demographics
NPI:1174500805
Name:LANGE, JARRETT (PT)
Entity Type:Individual
Prefix:
First Name:JARRETT
Middle Name:
Last Name:LANGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:
Practice Address - Street 1:4407 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5311
Practice Address - Country:US
Practice Address - Phone:432-366-9541
Practice Address - Fax:432-366-1951
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D1243Medicare ID - Type UnspecifiedMEDICARE
TXS90247Medicare UPIN