Healthcare Provider Details

I. General information

NPI: 1265758064
Provider Name (Legal Business Name): JENNIFER MARIE BEAL P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2366 NW LAKESIDE PL
BEND OR
97701-3535
US

IV. Provider business mailing address

1943 NW 22ND ST
REDMOND OR
97756-8449
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-0479
  • Fax:
Mailing address:
  • Phone: 541-280-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number7828
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: