Provider Demographics
NPI:1407370406
Name:LEUPOLD, JESSICA (MBA, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEUPOLD
Suffix:
Gender:F
Credentials:MBA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 BLUE QUAIL RD SW
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-7727
Mailing Address - Country:US
Mailing Address - Phone:575-312-4089
Mailing Address - Fax:
Practice Address - Street 1:1100 S NICKEL ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-6301
Practice Address - Country:US
Practice Address - Phone:575-312-4089
Practice Address - Fax:575-544-0918
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NM7302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer