Healthcare Provider Details

I. General information

NPI: 1538740634
Provider Name (Legal Business Name): MICHAEL JACOB JEPSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 HOSPITAL RD
NEW RICHMOND WI
54017-1449
US

IV. Provider business mailing address

6600 EXCELSIOR BLVD STE 160
ST LOUIS PARK MN
55426-4713
US

V. Phone/Fax

Practice location:
  • Phone: 715-243-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81640
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: