Healthcare Provider Details

I. General information

NPI: 1689687709
Provider Name (Legal Business Name): NEIL ALLEN JEPSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/19/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

611 W. PARK ST. FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number047000715
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0470000715
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0470000715
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: