Provider Demographics
NPI:1154994838
Name:BEAVER, JESSICA ROSE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:BEAVER
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 1:4 HIGGINS DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462-3025
Mailing Address - Country:US
Mailing Address - Phone:973-941-1237
Mailing Address - Fax:
Practice Address - Street 1:697 LOUISIANA RD BLDG 9201
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607-1141
Practice Address - Country:US
Practice Address - Phone:325-696-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians