Provider Demographics
NPI:1447219274
Name:BECKER, JENNIFER M (CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BECKER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 WOODWINDS DRIVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-702-0750
Mailing Address - Fax:651-645-6166
Practice Address - Street 1:2080 WOODWINDS DR
Practice Address - Street 2:SUITE 240
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2523
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:651-645-6166
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-137493-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN519160200Medicaid
MN519160200Medicaid