Healthcare Provider Details

I. General information

NPI: 1215343553
Provider Name (Legal Business Name): FREDERICK JOHN JAECKLEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE STE 300
MEMPHIS TN
38104-6655
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-272-6018
  • Fax: 901-201-4203
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number63733
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301095037
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: