Basic Information
| Provider Information | |||||||||
| NPI: | 1346261054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 278 VT ROUTE 149 | ||||||||
| Address2: | METTOWEE VALLEY FAMILY HEALTH CENTER | ||||||||
| City: | WEST PAWLET | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057759798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026450580 | ||||||||
| FaxNumber: | 8026450587 | ||||||||
| Practice Location | |||||||||
| Address1: | 278 VT ROUTE 149 | ||||||||
| Address2: | METTOWEE VALLEY FAMILY HEALTH CENTER | ||||||||
| City: | WEST PAWLET | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057759798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026450580 | ||||||||
| FaxNumber: | 8026450587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1010017766 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | F3335321 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ONP1463 | 05 | VT | MEDICAID | 01956770 | 05 | NY | MEDICAID |