Provider Demographics
NPI:1063260735
Name:BEUCK, JENNA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BEUCK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E 18TH ST APT B204
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3045
Mailing Address - Country:US
Mailing Address - Phone:949-648-0247
Mailing Address - Fax:
Practice Address - Street 1:3900 BIRCH ST STE 103
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2226
Practice Address - Country:US
Practice Address - Phone:949-955-0010
Practice Address - Fax:949-955-0033
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31635235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty