Provider Demographics
NPI:1326799958
Name:TALLEY BECK, JACOB K (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:K
Last Name:TALLEY BECK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5936 LIMESTONE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-8931
Mailing Address - Country:US
Mailing Address - Phone:302-239-4500
Mailing Address - Fax:302-489-5000
Practice Address - Street 1:5939 LIMESTONE ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707
Practice Address - Country:US
Practice Address - Phone:302-239-4500
Practice Address - Fax:302-489-5000
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50011662207Q00000X
DEC5-0011662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0011662OtherDE PROFESSIONAL LICENSE