Provider Demographics
NPI:1720638968
Name:BEEBE, TARA JO
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JO
Last Name:BEEBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3076 HENDEE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9001
Mailing Address - Country:US
Mailing Address - Phone:517-416-6104
Mailing Address - Fax:
Practice Address - Street 1:3076 HENDEE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9001
Practice Address - Country:US
Practice Address - Phone:517-416-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002790225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant