Healthcare Provider Details

I. General information

NPI: 1306828009
Provider Name (Legal Business Name): FREDERICK P JAECKLEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W. FAIR AVENUE STE 201
MARQUETTE MI
49855
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-4500
  • Fax: 906-225-3919
Mailing address:
  • Phone: 615-920-7000
  • Fax: 916-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number049842
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number049842
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: