Provider Demographics
NPI:1477258341
Name:BEAULIEU, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:
Practice Address - Street 1:1441 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-5420
Practice Address - Country:US
Practice Address - Phone:208-642-9376
Practice Address - Fax:208-642-9598
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID75717363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health