Provider Demographics
NPI:1477298677
Name:BEACH, JILL RENEE (LAC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:RENEE
Last Name:BEACH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 717
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442
Mailing Address - Country:US
Mailing Address - Phone:870-570-0358
Mailing Address - Fax:870-570-0359
Practice Address - Street 1:DELTA BEHAVIORAL HEALTH, LLC
Practice Address - Street 2:920 E. MEDICAL DRIVE
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-570-0358
Practice Address - Fax:870-570-0359
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2412004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR283638795Medicaid