Basic Information
Provider Information | |||||||||
NPI: | 1427112432 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEAUCHAMP | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: | COHAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1343 PEACHTREE BATTLE AVE NW | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303271423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043512480 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1967 LAKESIDE PKWY | ||||||||
Address2: | SUITE 420 | ||||||||
City: | TUCKER | ||||||||
State: | GA | ||||||||
PostalCode: | 300845867 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704140055 | ||||||||
FaxNumber: | 7704140045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 09/27/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | PT007659 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 918546041B | 05 | GA |   | MEDICAID |