Provider Demographics
NPI:1467930784
Name:BECKER, JEDIDIAH COLBY (PMHNP)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:COLBY
Last Name:BECKER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 STONERIDGE RD STE F101
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7759
Mailing Address - Country:US
Mailing Address - Phone:512-329-8222
Mailing Address - Fax:512-329-0087
Practice Address - Street 1:3660 STONERIDGE RD STE F101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-7759
Practice Address - Country:US
Practice Address - Phone:512-329-8222
Practice Address - Fax:512-329-0087
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138162363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health