Healthcare Provider Details

I. General information

NPI: 1871543033
Provider Name (Legal Business Name): JILL KELLEY BEASENBURG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 GRANNYS LN
AWENDAW SC
29429-6060
US

IV. Provider business mailing address

636 LONG POINT RD UNIT G
MT PLEASANT SC
29464-8286
US

V. Phone/Fax

Practice location:
  • Phone: 843-259-4633
  • Fax: 843-388-4498
Mailing address:
  • Phone: 843-259-4633
  • Fax: 843-388-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number4236
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: