Basic Information
| Provider Information | |||||||||
| NPI: | 1760910624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTZELL | ||||||||
| OtherFirstName: | JENNA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 68TH STREET SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319472255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 SILVER DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496845749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319472255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2017 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | 104100000X | 6801100864 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801104782 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.