Provider Demographics
NPI:1720713910
Name:BECK, JESSICA ROSE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:BECK
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:N1362 IRISH RD
Mailing Address - Street 2:
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-9506
Mailing Address - Country:US
Mailing Address - Phone:920-418-4265
Mailing Address - Fax:
Practice Address - Street 1:3360 GATEWAY RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5115
Practice Address - Country:US
Practice Address - Phone:262-923-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3001-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant