Provider Demographics
NPI:1265758064
Name:BEAL, JENNIFER MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BEAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1943 NW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8449
Mailing Address - Country:US
Mailing Address - Phone:541-280-4050
Mailing Address - Fax:
Practice Address - Street 1:2366 NW LAKESIDE PL
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3535
Practice Address - Country:US
Practice Address - Phone:541-382-0479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7828172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker