Provider Demographics
NPI:1326073537
Name:JEPSEN, KERRY GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:GLEN
Last Name:JEPSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:164 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1557
Mailing Address - Country:US
Mailing Address - Phone:208-847-4354
Mailing Address - Fax:208-847-4425
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003871207X00000X
UT290836-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery