Healthcare Provider Details

I. General information

NPI: 1821963653
Provider Name (Legal Business Name): BROOKE CAMPBELL JEPPESEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 S JUNIPER RD
MALTA ID
83342-8004
US

IV. Provider business mailing address

2502 S JUNIPER RD
MALTA ID
83342-8004
US

V. Phone/Fax

Practice location:
  • Phone: 208-670-0776
  • Fax: 208-670-0776
Mailing address:
  • Phone: 208-670-0776
  • Fax: 208-670-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6171981
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: