Basic Information
| Provider Information | |||||||||
| NPI: | 1679548143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 13279 N CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339034818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396524111 | ||||||||
| FaxNumber: | 2396524105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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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 | 363L00000X | ARNP9216538 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 307085900 | 05 | FL | MEDICAID |