Healthcare Provider Details

I. General information

NPI: 1912630476
Provider Name (Legal Business Name): JACOB WIEPEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW R D MIZE RD
BLUE SPRINGS MO
64014-2513
US

IV. Provider business mailing address

201 NW R D MIZE RD
BLUE SPRINGS MO
64014-2513
US

V. Phone/Fax

Practice location:
  • Phone: 816-228-5900
  • Fax:
Mailing address:
  • Phone: 816-228-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2022025670
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: