Healthcare Provider Details

I. General information

NPI: 1730323882
Provider Name (Legal Business Name): JACQUELINE LYNN BEELER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W TERRELL AVE FL 2
FORT WORTH TX
76104-2820
US

IV. Provider business mailing address

1300 W TERRELL AVE FL 2
FORT WORTH TX
76104-2820
US

V. Phone/Fax

Practice location:
  • Phone: 817-820-4906
  • Fax: 817-820-4815
Mailing address:
  • Phone: 817-820-4906
  • Fax: 817-820-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05824
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: