Provider Demographics
NPI:1932790524
Name:JEPPSON, SCOTT RUSSELL (PT,DPT,CERTVRS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RUSSELL
Last Name:JEPPSON
Suffix:
Gender:M
Credentials:PT,DPT,CERTVRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S HIGH SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:CO
Mailing Address - Zip Code:80734-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:CO
Practice Address - Zip Code:80734-1854
Practice Address - Country:US
Practice Address - Phone:970-854-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty