Healthcare Provider Details

I. General information

NPI: 1063260735
Provider Name (Legal Business Name): JENNA BEUCK MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 BIRCH ST STE 103
NEWPORT BEACH CA
92660-2226
US

IV. Provider business mailing address

126 E 18TH ST APT B204
COSTA MESA CA
92627-3045
US

V. Phone/Fax

Practice location:
  • Phone: 949-955-0010
  • Fax: 949-955-0033
Mailing address:
  • Phone: 949-648-0247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number31635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: