Provider Demographics
NPI:1053829028
Name:LEEPER, JAKE S
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:S
Last Name:LEEPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E LYNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3039
Mailing Address - Country:US
Mailing Address - Phone:406-396-6117
Mailing Address - Fax:
Practice Address - Street 1:1500 E LYNDALE AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3039
Practice Address - Country:US
Practice Address - Phone:406-396-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-23473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health