Healthcare Provider Details

I. General information

NPI: 1558757872
Provider Name (Legal Business Name): JEFFREY BECKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 30TH ST
DES MOINES IA
50310-5753
US

IV. Provider business mailing address

3808 GLASGOW DR
PLANO TX
75025-3839
US

V. Phone/Fax

Practice location:
  • Phone: 515-699-5800
  • Fax:
Mailing address:
  • Phone: 314-420-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2019024516
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD-45325
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberU6684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: