Provider Demographics
NPI:1699065110
Name:LANGE-HALLEY, JACQUELYN RAE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:RAE
Last Name:LANGE-HALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8936
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0016
Mailing Address - Country:US
Mailing Address - Phone:479-305-7201
Mailing Address - Fax:479-900-9930
Practice Address - Street 1:2580 E JOYCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3924
Practice Address - Country:US
Practice Address - Phone:479-305-7201
Practice Address - Fax:949-577-4833
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-91972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211861001Medicaid