Provider Demographics
NPI:1144205618
Name:YAEGER, JACKIE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LYNN
Last Name:YAEGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNN
Other - Last Name:BRISTOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3630
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32262-20207QH0002X
IA34247207Q00000X
WI32262207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE21923OtherMEDICAL LICENSE
IA34247OtherMEDICAL LICENSE
IA0235473Medicaid
SD5939OtherMEDICAL LICENSE
NE21923OtherMEDICAL LICENSE
IA34247OtherMEDICAL LICENSE