Provider Demographics
NPI:1184017030
Name:JEPSON WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:JEPSON WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JEPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-263-9961
Mailing Address - Street 1:11420 FM 2244 RD
Mailing Address - Street 2:STE A-100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5526
Mailing Address - Country:US
Mailing Address - Phone:512-263-9961
Mailing Address - Fax:512-263-9963
Practice Address - Street 1:11420 FM 2244 RD
Practice Address - Street 2:STE A-100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5526
Practice Address - Country:US
Practice Address - Phone:512-263-9961
Practice Address - Fax:512-263-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-16
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX442866Medicare PIN