Provider Demographics
NPI:1912191834
Name:BEATHE, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:BEATHE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101473
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99510-1473
Mailing Address - Country:US
Mailing Address - Phone:907-272-0855
Mailing Address - Fax:
Practice Address - Street 1:2550 DENALI ST
Practice Address - Street 2:SUITE 1608
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2783
Practice Address - Country:US
Practice Address - Phone:907-272-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical