Provider Demographics
NPI:1679941876
Name:BEACH, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:BEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MADISON STREET
Mailing Address - Street 2:P.O. BOX 154
Mailing Address - City:SHERIDAN
Mailing Address - State:MT
Mailing Address - Zip Code:59749
Mailing Address - Country:US
Mailing Address - Phone:979-530-3234
Mailing Address - Fax:
Practice Address - Street 1:101 MADISON STREET
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:MT
Practice Address - Zip Code:59749
Practice Address - Country:US
Practice Address - Phone:979-530-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer