Provider Demographics
NPI:1629021332
Name:JAEGLE, CONSTANCE (RN, MS, NP)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:
Last Name:JAEGLE
Suffix:
Gender:F
Credentials:RN, MS, NP
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:MCGILLICUDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1766 N 21ST RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61325-9662
Mailing Address - Country:US
Mailing Address - Phone:815-257-0007
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9509
Practice Address - Country:US
Practice Address - Phone:815-469-1367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041154564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS43287Medicare UPIN