Provider Demographics
NPI:1609644673
Name:JAECKEL, PAUL T (MS, RDN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:JAECKEL
Suffix:
Gender:M
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 130TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-1813
Mailing Address - Country:US
Mailing Address - Phone:631-942-0473
Mailing Address - Fax:
Practice Address - Street 1:301 W 130TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-1813
Practice Address - Country:US
Practice Address - Phone:631-942-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86299925133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered