Healthcare Provider Details

I. General information

NPI: 1750713384
Provider Name (Legal Business Name): BENJAMIN JEPPSEN M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 CHARLESTOWN RD
NEW ALBANY IN
47150-2536
US

IV. Provider business mailing address

3211 PLAZA DR APT 30
NEW ALBANY IN
47150-2429
US

V. Phone/Fax

Practice location:
  • Phone: 208-697-2720
  • Fax:
Mailing address:
  • Phone: 208-697-2720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: