MEDICARE: MR. JACOB CODY BEACH MSN,APRN,FNP-C, CEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0024177331	VA
2	163WE0003X	Emergency Registered Nurse	0001238176	VA

General Provider Information

NPI Number	:	1497169197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB CODY BEACH MSN,APRN,FNP-C, CEN

Provider Business Mailing Address
First Line	:	115 COLLEGE ST
Second Line	:
City	:	CLARKSVILLE
State	:	VA
Zip	:	23927-9125
Country	:	US
Telephone Number	:	434-374-5344
Fax Number	:

Provider Business Practice Location Address
First Line	:	414 PARK AVE
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-4630
Country	:	US
Telephone Number	:	434-857-3600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2014
Last Update Date	:	07/25/2022

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