Healthcare Provider Details

I. General information

NPI: 1992667307
Provider Name (Legal Business Name): JESSICA BEATY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S POKEGAMA AVE
GRAND RAPIDS MN
55744-3635
US

IV. Provider business mailing address

319 S POKEGAMA AVE
GRAND RAPIDS MN
55744-3635
US

V. Phone/Fax

Practice location:
  • Phone: 218-410-0650
  • Fax:
Mailing address:
  • Phone: 218-410-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: