Provider Demographics
NPI:1760746150
Name:LANGE, JESSICA LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:LANGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N EAGLE CREEK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1827
Mailing Address - Country:US
Mailing Address - Phone:859-629-7140
Mailing Address - Fax:859-629-7137
Practice Address - Street 1:120 N EAGLE CREEK DR STE 102
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1827
Practice Address - Country:US
Practice Address - Phone:859-629-7140
Practice Address - Fax:859-629-7137
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2561207Y00000X
KY50404207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100472170Medicaid