Provider Demographics
NPI:1952595118
Name:LEEPER, JENNIFER L (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LEEPER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 COMMODORE ST
Mailing Address - Street 2:STE B
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-2993
Mailing Address - Country:US
Mailing Address - Phone:620-672-6454
Mailing Address - Fax:
Practice Address - Street 1:124 COMMODORE ST
Practice Address - Street 2:STE B
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2993
Practice Address - Country:US
Practice Address - Phone:620-672-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-01537363A00000X
KS1501224363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200477850BMedicaid
KS200477850BMedicaid