Provider Demographics
NPI:1699338442
Name:JEPSEN, AMANDA LEIGH (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:JEPSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 476 BOX 25
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96322-0001
Mailing Address - Country:US
Mailing Address - Phone:315-252-2557
Mailing Address - Fax:
Practice Address - Street 1:PSC 476 BOX 25
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96322-0001
Practice Address - Country:US
Practice Address - Phone:315-252-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine