Provider Demographics
NPI:1144619057
Name:JEPPERSON, JEFFREY JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JON
Last Name:JEPPERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 POPE AVE
Mailing Address - Street 2:US ARMY DENTAL ACTIVTY
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:913-684-5516
Mailing Address - Fax:
Practice Address - Street 1:520 POPE AVE
Practice Address - Street 2:US ARMY DENTAL ACTIVTY
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9039485-99221223G0001X
KS61083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice