=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124227723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER L BECK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2007
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 WIND HAVEN DR STE 104
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-8036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-888-5233
-----------------------------------------------------
Fax | 318-232-5983
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 WIND HAVEN DR STE 104
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-8036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-888-5233
-----------------------------------------------------
Fax | 318-232-5983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 40245
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------