Provider Demographics
NPI:1609131630
Name:BEAUDETTE, JESSICA LYNN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BEAUDETTE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 MURPHY CANYON RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5151 MURPHY CANYON RD STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4480
Practice Address - Country:US
Practice Address - Phone:619-275-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31327225100000X
TX1206461225100000X
OR06765225100000X
CA39024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist