Healthcare Provider Details

I. General information

NPI: 1134874886
Provider Name (Legal Business Name): HEIDI JAECKLE ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4081 CASCADE RD SE STE 100
GRAND RAPIDS MI
49546-2170
US

IV. Provider business mailing address

6118 MONTMORENCY DR SE
CALEDONIA MI
49316-8059
US

V. Phone/Fax

Practice location:
  • Phone: 616-319-1978
  • Fax:
Mailing address:
  • Phone: 518-669-6034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451020894
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: