Healthcare Provider Details

I. General information

NPI: 1497703318
Provider Name (Legal Business Name): JACQUES L BEAUCHAMP PT,DPT,SCS,OCS,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4216 WASHINGTON RD STE 2
EVANS GA
30809-4717
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 706-814-5460
  • Fax: 706-814-5574
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-300-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000993
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007231
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier095783718B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: