Basic Information
| Provider Information | |||||||||
| NPI: | 1629450366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOST | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | BEASLEY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPAT, ATR-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2141 SPENCER CT | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400316742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022227210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | 114296 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.