Provider Demographics
NPI:1730451311
Name:BEACH, JESSICA SUE (OTR)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SUE
Last Name:BEACH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:803 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-6342
Mailing Address - Country:US
Mailing Address - Phone:989-708-1212
Mailing Address - Fax:
Practice Address - Street 1:449 QUARTER ST
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1918
Practice Address - Country:US
Practice Address - Phone:989-426-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008148225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201008148OtherBOARD OF OCCUPATIONAL THERAPY