Provider Demographics
NPI:1790806982
Name:LANGE, JENNIFER MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
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 1:615 HAMPSHIRE RD
Mailing Address - Street 2:APT #6
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-4200
Mailing Address - Country:US
Mailing Address - Phone:937-838-9319
Mailing Address - Fax:
Practice Address - Street 1:615 HAMPSHIRE RD
Practice Address - Street 2:APT. #6
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-4200
Practice Address - Country:US
Practice Address - Phone:937-838-9319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05420225200000X
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant