Provider Demographics
NPI:1851349955
Name:BECKER, JACK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:BECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:484-628-1324
Mailing Address - Fax:
Practice Address - Street 1:233 E LANCASTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003
Practice Address - Country:US
Practice Address - Phone:610-642-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMDO42717E207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001252808Medicaid
PA673732OtherHIGHMARK PIN
PA0012528080011Medicaid
PA673732Medicare PIN