Healthcare Provider Details

I. General information

NPI: 1497370514
Provider Name (Legal Business Name): JANTIMA SHANNON BECKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 320
LA JOLLA CA
92037-1208
US

IV. Provider business mailing address

1060 CROSSWATER DR
RENO NV
89523-7100
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-1212
  • Fax: 858-795-1195
Mailing address:
  • Phone: 775-354-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: