Basic Information
| Provider Information | |||||||||
| NPI: | 1497703318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | JACQUES | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT,DPT,SCS,OCS,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063001612 | ||||||||
| Practice Location | |||||||||
| Address1: | 4216 WASHINGTON RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308094717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068145460 | ||||||||
| FaxNumber: | 7068145574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT000993 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PT007231 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 095783718B | 05 | GA | MEDICAID |