Provider Demographics
NPI:1205825650
Name:JAECKLE, KURT ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:ALFRED
Last Name:JAECKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:973-290-7495
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09911100207RX0202X, 2084N0400X
FLME800852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49850OtherBLUECROSS/BLUESHIELD
FL130022008OtherRAILROAD MEDICARE
FL130022008OtherRAILROAD MEDICARE
FLC63570Medicare UPIN