Provider Demographics
NPI:1225082977
Name:BEAUDREAU, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BEAUDREAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1399
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-1399
Mailing Address - Country:US
Mailing Address - Phone:706-447-1280
Mailing Address - Fax:
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:EMERGENCY DEPT UNIVERSITY HOSPITAL
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31002208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ746092Medicaid
GAH70841Medicare UPIN
AZ109414Medicare ID - Type Unspecified
AZ746092Medicaid