Provider Demographics
NPI:1629200803
Name:LANG, JESSICA JEANNE (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEANNE
Last Name:LANG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 KAINS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1015
Mailing Address - Country:US
Mailing Address - Phone:714-495-9589
Mailing Address - Fax:
Practice Address - Street 1:333 SUNSET AVE # DR188
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-2003
Practice Address - Country:US
Practice Address - Phone:714-495-9589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66384101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner