Provider Demographics
NPI:1386760791
Name:LANG, JENNIFER BUCKLEY (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BUCKLEY
Last Name:LANG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 BLAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4288
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:1905 BLAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4288
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003241363LF0000X
CO0001726176B00000X
CO0109819163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07109812Medicaid
COCOAAA2137Medicare PIN
COCOAAA2137Medicare PIN