Provider Demographics
NPI:1245581222
Name:PRANGE, JESSICA LYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:PRANGE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYN
Other - Last Name:CREUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:15451 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3014
Practice Address - Country:US
Practice Address - Phone:818-501-5016
Practice Address - Fax:818-501-5003
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT12443225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist