Provider Demographics
NPI:1760675219
Name:BEASON, JACQUELINE (OTR)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BEASON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4182 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6954
Mailing Address - Country:US
Mailing Address - Phone:414-689-5139
Mailing Address - Fax:414-444-4833
Practice Address - Street 1:4182 N 13TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6954
Practice Address - Country:US
Practice Address - Phone:414-688-5139
Practice Address - Fax:414-444-4833
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-18
Last Update Date:2007-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40671200Medicaid