Provider Demographics
NPI:1003342148
Name:BEASLEY, JEREMY (PT,DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 SW 9TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6454
Mailing Address - Country:US
Mailing Address - Phone:239-671-9188
Mailing Address - Fax:
Practice Address - Street 1:13010 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4701
Practice Address - Country:US
Practice Address - Phone:239-561-5616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist