Provider Demographics
NPI:1427112432
Name:BEAUCHAMP, JENNY COHAN (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:COHAN
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 PEACHTREE BATTLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1423
Mailing Address - Country:US
Mailing Address - Phone:404-351-2480
Mailing Address - Fax:
Practice Address - Street 1:1967 LAKESIDE PKWY
Practice Address - Street 2:SUITE 420
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5867
Practice Address - Country:US
Practice Address - Phone:770-414-0055
Practice Address - Fax:770-414-0045
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0076592251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA918546041BMedicaid