Provider Demographics
NPI:1033876768
Name:EVANS JEPSEN, ANISSA (EDD)
Entity Type:Individual
Prefix:DR
First Name:ANISSA
Middle Name:
Last Name:EVANS JEPSEN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 JIM ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-6863
Mailing Address - Country:US
Mailing Address - Phone:712-260-1564
Mailing Address - Fax:
Practice Address - Street 1:3412 JIM ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-6863
Practice Address - Country:US
Practice Address - Phone:712-260-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123056103K00000X
1-23-65817103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst