Basic Information
| Provider Information | |||||||||
| NPI: | 1912129354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22180 OLYMPIC COLLEGE WAY NW STE 102 | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983706664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607794444 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 853 N CHURCH ST | ||||||||
| Address2: | SUITE 720A | ||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293033098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645606844 | ||||||||
| FaxNumber: | 8645607015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 35487 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 49636 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | TL35487 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | MD60795325 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | P01194322 | 01 | SC | RAILROAD MEDICARE | OTHER | 354878 | 05 | SC | MEDICAID | 2094534 | 05 | WA | MEDICAID |