Provider Demographics
NPI:1386048247
Name:JEPPSON, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:JEPPSON
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 1:225 MURIEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7568
Mailing Address - Country:US
Mailing Address - Phone:320-493-8522
Mailing Address - Fax:
Practice Address - Street 1:3018 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4282
Practice Address - Country:US
Practice Address - Phone:320-493-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN411946275390200000X
MNCC02209101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program