Provider Demographics
NPI:1346261054
Name:BECKER, JACQUELINE M (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:BECKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:278 VT ROUTE 149
Mailing Address - Street 2:METTOWEE VALLEY FAMILY HEALTH CENTER
Mailing Address - City:WEST PAWLET
Mailing Address - State:VT
Mailing Address - Zip Code:05775-9798
Mailing Address - Country:US
Mailing Address - Phone:802-645-0580
Mailing Address - Fax:802-645-0587
Practice Address - Street 1:278 VT ROUTE 149
Practice Address - Street 2:METTOWEE VALLEY FAMILY HEALTH CENTER
Practice Address - City:WEST PAWLET
Practice Address - State:VT
Practice Address - Zip Code:05775-9798
Practice Address - Country:US
Practice Address - Phone:802-645-0580
Practice Address - Fax:802-645-0587
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT1010017766363L00000X
NYF3335321363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP1463Medicaid
NY01956770Medicaid
VTONP1463Medicaid
NY01956770Medicaid