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General NPI Number Information
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NPI Number | 1104133867
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Entity Type | Individual
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Provider Name | CARISSA MARIE JAECKS D.C.
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Gender | Female
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Dates
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Enumeration Date | 09/01/2010
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Last Update Date | 12/01/2017
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Provider Practice Location Address
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Address Line | 1620 N SHAWANO ST STE E
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City | NEW LONDON
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State | WI
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Zip | 54961-9318
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Country | US
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Telephone | 920-982-5533
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Fax |
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Provider Business Mailing Address
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Address Line | 702 EISENHOWER DR STE G
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City | KIMBERLY
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State | WI
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Zip | 54136-2152
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Country | US
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Telephone | 715-281-4179
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4599-12
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License Number State | WI
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