Healthcare Provider Details

I. General information

NPI: 1003727116
Provider Name (Legal Business Name): MR. ETHAN JEPMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 SE 164TH AVE
VANCOUVER WA
98683-9314
US

IV. Provider business mailing address

3000 SE 164TH AVE
VANCOUVER WA
98683-9314
US

V. Phone/Fax

Practice location:
  • Phone: 360-553-1041
  • Fax:
Mailing address:
  • Phone: 360-553-1041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: