Provider Demographics
NPI:1952440299
Name:BEASLEY, WILLIS JEROME (MC)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:JEROME
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MC
Mailing Address - Street 1:333 W WILCOX
Mailing Address - Street 2:STE 303
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-378-2613
Mailing Address - Fax:520-458-5124
Practice Address - Street 1:333 W WILCOX
Practice Address - Street 2:STE 303
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-378-2613
Practice Address - Fax:520-458-5124
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC10904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ307442OtherMHN