Provider Demographics
NPI:1720735640
Name:LAGE, JENNIFER MICHELLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:LAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:423 GREAT OAK DR
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-2507
Practice Address - Country:US
Practice Address - Phone:320-281-5305
Practice Address - Fax:320-281-5306
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist