Healthcare Provider Details

I. General information

NPI: 1760356372
Provider Name (Legal Business Name): JONATHAN LANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 KOELLE BLVD
SECAUCUS NJ
07094-4228
US

IV. Provider business mailing address

1065 KOELLE BLVD
SECAUCUS NJ
07094-4228
US

V. Phone/Fax

Practice location:
  • Phone: 201-774-3740
  • Fax:
Mailing address:
  • Phone: 201-774-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26NJ15437600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: