Healthcare Provider Details

I. General information

NPI: 1881451235
Provider Name (Legal Business Name): JORDAN LANDON LANGE AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S 4TH ST STE 550
SAINT LOUIS MO
63102-1897
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax:
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number235430
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberH190105
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-5820-0
License Number StateHI
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2024008286
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3-002934
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: