Provider Demographics
NPI:1134430838
Name:BECKER, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 FISHERS STATION DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9744
Mailing Address - Country:US
Mailing Address - Phone:585-924-7207
Mailing Address - Fax:585-924-7049
Practice Address - Street 1:590 FISHERS STATION DR
Practice Address - Street 2:SUITE 130
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9744
Practice Address - Country:US
Practice Address - Phone:585-924-7207
Practice Address - Fax:585-924-7049
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053432-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30-0213081OtherTAX ID