Provider Demographics
NPI:1841807567
Name:LANGE, JESSICA (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:THETFORD CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05075-4410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7062
Practice Address - Country:US
Practice Address - Phone:619-876-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0134027171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist