Healthcare Provider Details

I. General information

NPI: 1013609932
Provider Name (Legal Business Name): JENNA HEPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 N 4TH ST STE 103
LARAMIE WY
82072-2091
US

IV. Provider business mailing address

3435 E WILLETT DR BUILDING 5 APT. 538
LARAMIE WY
82070
US

V. Phone/Fax

Practice location:
  • Phone: 307-721-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPPC-1284
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: