Healthcare Provider Details

I. General information

NPI: 1790167187
Provider Name (Legal Business Name): KENNETH JEPPESEN AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 N UNIVERSITY AVE STE 350
PROVO UT
84604-6602
US

IV. Provider business mailing address

3507 N UNIVERSITY AVE STE 350
PROVO UT
84604-6602
US

V. Phone/Fax

Practice location:
  • Phone: 801-477-0041
  • Fax:
Mailing address:
  • Phone: 801-477-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6001151-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: