Healthcare Provider Details

I. General information

NPI: 1316511330
Provider Name (Legal Business Name): MICHAEL JEPPESEN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 N WHITLEY DR
FRUITLAND ID
83619-2132
US

IV. Provider business mailing address

PO BOX 1665
NAMPA ID
83653-1665
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-7197
  • Fax:
Mailing address:
  • Phone: 208-800-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8671535
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: