MEDICARE: JONATHAN HOWARD BEAL LMSW

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	104100000X	Social Worker	6801085483	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6801085483	OTHER	MI	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1588134555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN HOWARD BEAL LMSW

Provider Business Mailing Address
First Line	:	59087 PINE GROVE RD
Second Line	:
City	:	COLON
State	:	MI
Zip	:	49040-9747
Country	:	US
Telephone Number	:	269-317-8229
Fax Number	:

Provider Business Practice Location Address
First Line	:	6120 STADIUM DR STE 100
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49009-3022
Country	:	US
Telephone Number	:	800-379-1600
Fax Number	:

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

Provider Enumeration Date	:	12/03/2018
Last Update Date	:	12/03/2018

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