Provider Demographics
NPI:1053807057
Name:BEAL, JESSICA ANN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:BEAL
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 1:4101 WOODLAKE PL APT E
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6547
Mailing Address - Country:US
Mailing Address - Phone:330-635-4073
Mailing Address - Fax:
Practice Address - Street 1:2900 KIDD RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1862
Practice Address - Country:US
Practice Address - Phone:919-532-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health