Provider Demographics
NPI:1215582192
Name:LANGE, JORDAN D (ATC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:D
Last Name:LANGE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 CLEARWATER RD APT 206
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-8601
Mailing Address - Country:US
Mailing Address - Phone:218-396-0160
Mailing Address - Fax:
Practice Address - Street 1:4020 CLEARWATER RD APT 206
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-8601
Practice Address - Country:US
Practice Address - Phone:218-396-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer