Basic Information
| Provider Information | |||||||||
| NPI: | 1295760312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 HARVARD DR | ||||||||
| Address2: | DR | ||||||||
| City: | FT MITCHELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410172835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593313424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2915 CLIFTON AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452202402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138722000 | ||||||||
| FaxNumber: | 5132818842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011080 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.