Provider Demographics
NPI:1508413790
Name:BEAUSOLEIL, JESSICA MAE (DPT, PT)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MAE
Last Name:BEAUSOLEIL
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-6687
Mailing Address - Country:US
Mailing Address - Phone:860-428-4298
Mailing Address - Fax:
Practice Address - Street 1:930 W CENTERVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5854
Practice Address - Country:US
Practice Address - Phone:792-303-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1320285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist