Provider Demographics
NPI:1598747180
Name:LEEPER, JODI K (PAC)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:K
Last Name:LEEPER
Suffix:
Gender:
Credentials:PAC
Other - Prefix:MISS
Other - First Name:JODI
Other - Middle Name:K
Other - Last Name:BERHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:70 VILLAGE LOOP RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 VILLAGE LOOP RD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2793
Practice Address - Country:US
Practice Address - Phone:406-752-8877
Practice Address - Fax:406-756-3245
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-58794363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200430690AMedicaid
KS033B038BMedicare PIN
KS200430690AMedicaid