Basic Information
Provider Information | |||||||||
NPI: | 1457619033 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEMPLER | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | KELLY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KELLY | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7609 | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598077609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067215600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2835 FORT MISSOULA RD BLDG 3 | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598047423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067215600 | ||||||||
FaxNumber: | 4063297192 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2012 | ||||||||
LastUpdateDate: | 06/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 67080 | MT | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.