Provider Demographics
NPI:1821564808
Name:BEAN, JAYLYNN (ATC)
Entity Type:Individual
Prefix:
First Name:JAYLYNN
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17555 IDA WEST RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49270-9564
Mailing Address - Country:US
Mailing Address - Phone:734-279-1012
Mailing Address - Fax:
Practice Address - Street 1:17555 IDA WEST RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:MI
Practice Address - Zip Code:49270-9564
Practice Address - Country:US
Practice Address - Phone:734-279-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI26010026032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program