Provider Demographics
NPI:1306828009
Name:JAECKLEIN, FREDERICK P (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:JAECKLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:916-920-8775
Practice Address - Street 1:1414 W. FAIR AVENUE
Practice Address - Street 2:STE 201
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-4500
Practice Address - Fax:906-225-3919
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI049842207RH0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110030846OtherRAILROAD MEDICARE
MI381358036011OtherTRICARE
MI3138366Medicaid
MI110030846OtherRAILROAD MEDICARE
MI381358036011OtherTRICARE