Provider Demographics
NPI:1518256940
Name:BEACH, JESSICA LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:BEACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8725 SE 159TH LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-5642
Mailing Address - Country:US
Mailing Address - Phone:352-315-7900
Mailing Address - Fax:352-360-6582
Practice Address - Street 1:215 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5105
Practice Address - Country:US
Practice Address - Phone:352-315-7900
Practice Address - Fax:352-360-6582
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 10312104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003422900Medicaid
FLEW627ZOtherMEDICARE PTAN