Provider Demographics
NPI:1598747180
Name:LEEPER, JODI K (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:K
Last Name:LEEPER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:JODI
Other - Middle Name:K
Other - Last Name:BERHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:160 HERITAGE WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3127
Mailing Address - Country:US
Mailing Address - Phone:406-752-8433
Mailing Address - Fax:406-756-6768
Practice Address - Street 1:160 HERITAGE WAY STE 202
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3127
Practice Address - Country:US
Practice Address - Phone:406-752-8433
Practice Address - Fax:406-756-6768
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-58794363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200430690AMedicaid
KS033B038BMedicare PIN
KS200430690AMedicaid