Provider Demographics
NPI:1740582337
Name:BEACH, JESSIKA LEIGH (LVN)
Entity Type:Individual
Prefix:
First Name:JESSIKA
Middle Name:LEIGH
Last Name:BEACH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W 56TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-5301
Mailing Address - Country:US
Mailing Address - Phone:909-205-3191
Mailing Address - Fax:
Practice Address - Street 1:845 W 56TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-5301
Practice Address - Country:US
Practice Address - Phone:909-205-3191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN206253164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse