Healthcare Provider Details

I. General information

NPI: 1538713656
Provider Name (Legal Business Name): JESSICA NICOLE MILLER-LANGE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S WALNUT AVE
AMES IA
50010-6974
US

IV. Provider business mailing address

106 MONROE ST N
HAZLETON IA
50641-9709
US

V. Phone/Fax

Practice location:
  • Phone: 515-233-1122
  • Fax:
Mailing address:
  • Phone: 319-283-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: