Healthcare Provider Details

I. General information

NPI: 1326073537
Provider Name (Legal Business Name): KERRY GLEN JEPSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-8757
  • Fax:
Mailing address:
  • Phone: 208-847-4354
  • Fax: 208-847-4425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2018003871
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number290836-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: