Provider Demographics
NPI:1609151224
Name:BEACH, JONATHAN JACK (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JACK
Last Name:BEACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MERIDIAN CROSSINGS
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4584
Mailing Address - Country:US
Mailing Address - Phone:517-347-2495
Mailing Address - Fax:517-347-3540
Practice Address - Street 1:3536 MERIDIAN CROSSINGS
Practice Address - Street 2:SUITE 240
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4584
Practice Address - Country:US
Practice Address - Phone:517-347-2495
Practice Address - Fax:517-347-3540
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist