Provider Demographics
NPI:1962441147
Name:BECKER, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:990 W ANN ARBOR TRL
Practice Address - Street 2:SUITE 210
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6204
Practice Address - Country:US
Practice Address - Phone:734-455-4600
Practice Address - Fax:734-455-5637
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046320208000000X
MI4301063055208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8451692Medicaid
WA8860477Medicare PIN