Provider Demographics
NPI:1194221200
Name:BECKER, JENNIFER JO (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:BECKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1489
Mailing Address - Country:US
Mailing Address - Phone:314-802-2610
Mailing Address - Fax:314-371-6508
Practice Address - Street 1:2650 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1489
Practice Address - Country:US
Practice Address - Phone:314-802-2610
Practice Address - Fax:314-371-6508
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021036669363LP0808X
MO2017036480363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420066013Medicaid