Healthcare Provider Details

I. General information

NPI: 1497169197
Provider Name (Legal Business Name): JACOB CODY BEACH MSN,APRN,FNP-C, CEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PARK AVE
DANVILLE VA
24541-4630
US

IV. Provider business mailing address

115 COLLEGE ST
CLARKSVILLE VA
23927-9125
US

V. Phone/Fax

Practice location:
  • Phone: 434-857-3600
  • Fax:
Mailing address:
  • Phone: 434-374-5344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024177331
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number0001238176
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: