Provider Demographics
NPI:1649894668
Name:KEPKE, JENNIFER ELAINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:KEPKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 GREENWYCK DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8530
Mailing Address - Country:US
Mailing Address - Phone:972-265-9124
Mailing Address - Fax:
Practice Address - Street 1:5445 LEGACY DR STE 270
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3363
Practice Address - Country:US
Practice Address - Phone:972-265-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79649101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty