Healthcare Provider Details

I. General information

NPI: 1407370406
Provider Name (Legal Business Name): JESSICA LEUPOLD MBA, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S NICKEL ST
DEMING NM
88030-6301
US

IV. Provider business mailing address

3530 BLUE QUAIL RD SW
DEMING NM
88030-7727
US

V. Phone/Fax

Practice location:
  • Phone: 575-312-4089
  • Fax: 575-544-0918
Mailing address:
  • Phone: 575-312-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number730
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: