Provider Demographics
NPI:1215117122
Name:PERSON, JENNIFER BEACHAM (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BEACHAM
Last Name:PERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-1139
Mailing Address - Country:US
Mailing Address - Phone:910-376-0225
Mailing Address - Fax:
Practice Address - Street 1:315 GREENVILLE BLVD SE STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5733
Practice Address - Country:US
Practice Address - Phone:252-917-5621
Practice Address - Fax:252-565-8722
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK138960363A00000X
WAPA60685346363A00000X
NC0010-01128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant