Healthcare Provider Details

I. General information

NPI: 1144205618
Provider Name (Legal Business Name): JACKIE LYNN YAEGER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE LYNN BRISTOW MD

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MAPLE LN STE 1
ASHLAND WI
54806-3630
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-7500
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number32262-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: