Provider Demographics
NPI:1922215920
Name:BECKER, JASON E
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:BECKER
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 1:2900 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-1748
Mailing Address - Country:US
Mailing Address - Phone:309-688-3616
Mailing Address - Fax:309-687-3370
Practice Address - Street 1:2900 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-1748
Practice Address - Country:US
Practice Address - Phone:309-688-3616
Practice Address - Fax:309-687-3370
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036118738208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118738Medicaid
IL036118738Medicaid
ILK39380Medicare PIN