Provider Demographics
NPI:1477596534
Name:JAEGER, MARY ALICE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ALICE
Middle Name:ELIZABETH
Last Name:JAEGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8607 W DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-9603
Mailing Address - Country:US
Mailing Address - Phone:208-699-7644
Mailing Address - Fax:
Practice Address - Street 1:1717 LINCOLN WAY STE 203
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-3341
Practice Address - Fax:208-664-8973
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34507207QS1201X
IDM6380207QS1201X
WA60104935207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002728300Medicaid
ID002728300Medicaid
1129640Medicare ID - Type Unspecified