Provider Demographics
NPI:1346487618
Name:JEPSEN, KYLE DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DAVID
Last Name:JEPSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4345 NATHAN LN N
Mailing Address - Street 2:STE. F
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-4522
Mailing Address - Country:US
Mailing Address - Phone:763-536-1112
Mailing Address - Fax:763-536-0471
Practice Address - Street 1:4345 NATHAN LN N
Practice Address - Street 2:STE. F
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-4522
Practice Address - Country:US
Practice Address - Phone:763-536-1112
Practice Address - Fax:763-536-0471
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor