Healthcare Provider Details

I. General information

NPI: 1356469985
Provider Name (Legal Business Name): MRS. JEANNI CLANCEY LANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 D ST
SAN RAFAEL CA
94901
US

IV. Provider business mailing address

PO BOX 478
FIARFAX CA
94978-0478
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-6058
  • Fax: 415-454-6078
Mailing address:
  • Phone: 415-454-6058
  • Fax: 415-454-6078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: