Healthcare Provider Details

I. General information

NPI: 1477258341
Provider Name (Legal Business Name): JENNIFER MARIE BEAULIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER CRAIN

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

IV. Provider business mailing address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9376
  • Fax: 208-642-9598
Mailing address:
  • Phone: 208-642-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10007694
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number75717
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: