Provider Demographics
NPI:1821528472
Name:BEALL, JEDEDIAH CHARLES
Entity Type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:CHARLES
Last Name:BEALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8540
Mailing Address - Country:US
Mailing Address - Phone:707-479-8697
Mailing Address - Fax:
Practice Address - Street 1:440 ARROWOOD DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7503
Practice Address - Country:US
Practice Address - Phone:707-284-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)