Healthcare Provider Details

I. General information

NPI: 1861672446
Provider Name (Legal Business Name): JEPPE CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4491 N DRESDEN PL STE 3
GARDEN CITY ID
83714-1391
US

IV. Provider business mailing address

4491 N DRESDEN PL STE 3
GARDEN CITY ID
83714-1391
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-1190
  • Fax: 208-323-6508
Mailing address:
  • Phone: 208-378-1190
  • Fax: 208-323-6508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1048
License Number StateID

VIII. Authorized Official

Name: BENJAMIN E JEPPE
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 208-378-1190