Provider Demographics
NPI:1649969247
Name:BECKER, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
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 1:2004 STATE ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3957
Mailing Address - Country:US
Mailing Address - Phone:641-780-1230
Mailing Address - Fax:
Practice Address - Street 1:1000 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-2909
Practice Address - Country:US
Practice Address - Phone:641-780-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1060760225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist