Provider Demographics
NPI:1083393078
Name:BEACH, JACIE LYN (PA)
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:LYN
Last Name:BEACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:108 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-6604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 PARK AVE
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-6604
Practice Address - Country:US
Practice Address - Phone:828-783-9183
Practice Address - Fax:828-783-9184
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-13309363A00000X
TN5660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant