Healthcare Provider Details

I. General information

NPI: 1467003962
Provider Name (Legal Business Name): REBECCA BEAUPRE JACKWICZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1913 ATLANTIC AVE
MANASQUAN NJ
08736-1029
US

IV. Provider business mailing address

1913 ATLANTIC AVE SUITE 160 FIRST FLOOR
MANASQUAN NJ
08736-1029
US

V. Phone/Fax

Practice location:
  • Phone: 732-487-1808
  • Fax: 732-681-3061
Mailing address:
  • Phone: 732-487-1808
  • Fax: 732-681-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00955000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00955000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: