Basic Information
| Provider Information | |||||||||
| NPI: | 1285862458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECK | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | FEDASH | ||||||||
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| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 BEACON DR | ||||||||
| Address2: | SUITE I | ||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285907860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523531114 | ||||||||
| FaxNumber: | 2523531119 | ||||||||
| Practice Location | |||||||||
| Address1: | 154 BEACON DR | ||||||||
| Address2: | SUITE I | ||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285907860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523531114 | ||||||||
| FaxNumber: | 2523531119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 7076 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6104243 | 05 | NC | MEDICAID |