MEDICARE: MRS. JOAN G JAECKLE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	21607	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326046046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOAN G JAECKLE LCSW

Provider Business Mailing Address
First Line	:	9607 CHAMPIONS DR
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76049-4480
Country	:	US
Telephone Number	:	817-736-8005
Fax Number	:	817-886-6641

Provider Business Practice Location Address
First Line	:	9607 CHAMPIONS DR
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76049-4480
Country	:	US
Telephone Number	:	817-736-8005
Fax Number	:	817-886-6641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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