Provider Demographics
NPI:1659419414
Name:LANGE, JESSICA M (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:LANGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2031
Mailing Address - Country:US
Mailing Address - Phone:712-732-7725
Mailing Address - Fax:712-732-5153
Practice Address - Street 1:315 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1743
Practice Address - Country:US
Practice Address - Phone:712-732-7725
Practice Address - Fax:712-732-5153
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1014225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant