Provider Demographics
NPI:1942508965
Name:LANGE, JESSICA (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 W NORTH AVE
Mailing Address - Street 2:BUILDING B, SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4637
Mailing Address - Country:US
Mailing Address - Phone:262-785-1500
Mailing Address - Fax:262-785-1555
Practice Address - Street 1:12720 W NORTH AVE
Practice Address - Street 2:BUILDING B SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4637
Practice Address - Country:US
Practice Address - Phone:262-285-1500
Practice Address - Fax:262-785-1555
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4525-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional