Provider Demographics
NPI:1508603812
Name:JEPSEN-BAKKE, JACQUE
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:JEPSEN-BAKKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUE
Other - Middle Name:
Other - Last Name:JEPSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3412 JIM ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-6863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3412 JIM ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-6863
Practice Address - Country:US
Practice Address - Phone:850-797-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician