Basic Information
| Provider Information | |||||||||
| NPI: | 1730451311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEACH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | SUE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 803 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486426342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897081212 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 449 QUARTER ST | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894263430 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201008148 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5201008148 | 01 | MI | BOARD OF OCCUPATIONAL THERAPY | OTHER |