Provider Demographics
NPI:1477596385
Name:BECKWITH, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BECKWITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 CHESHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3706
Mailing Address - Country:US
Mailing Address - Phone:888-333-9152
Mailing Address - Fax:763-268-4240
Practice Address - Street 1:1199 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5912
Practice Address - Country:US
Practice Address - Phone:386-252-6111
Practice Address - Fax:386-257-5826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS1775237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist