Provider Demographics
NPI:1598702367
Name:JEPPE, BENJAMIN EDWARD (DC, AGPCNP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:JEPPE
Suffix:
Gender:M
Credentials:DC, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW GARDEN VALLEY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1636
Mailing Address - Country:US
Mailing Address - Phone:541-464-0788
Mailing Address - Fax:
Practice Address - Street 1:1700 NW GARDEN VALLEY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1636
Practice Address - Country:US
Practice Address - Phone:541-464-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2021108518NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner