Provider Demographics
NPI:1497703318
Name:BEAUCHAMP, JACQUES L (PT,DPT,SCS,OCS,ATC)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:L
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:PT,DPT,SCS,OCS,ATC
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 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:4216 WASHINGTON RD STE 2
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4717
Practice Address - Country:US
Practice Address - Phone:706-814-5460
Practice Address - Fax:706-814-5574
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0009932255A2300X
GAPT007231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA095783718BMedicaid
GA65BBCKZMedicare ID - Type UnspecifiedPROVIDER NUMBER