MEDICARE: JESSICA M LANGE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1014	IA

General Provider Information

NPI Number	:	1659419414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA M LANGE PTA

Provider Business Mailing Address
First Line	:	1017 SENECA ST
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-2031
Country	:	US
Telephone Number	:	712-732-7725
Fax Number	:	712-732-5153

Provider Business Practice Location Address
First Line	:	315 W 5TH ST
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-1743
Country	:	US
Telephone Number	:	712-732-7725
Fax Number	:	712-732-5153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	07/08/2007

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Directions to “ JESSICA M LANGE PTA” Practice Location

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