Provider Demographics
NPI:1851340772
Name:JAECK, MARY DIANE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DIANE
Last Name:JAECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 HIGH POINTE CT
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2650
Mailing Address - Country:US
Mailing Address - Phone:419-447-0398
Mailing Address - Fax:
Practice Address - Street 1:26 HIGH POINTE CT
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2650
Practice Address - Country:US
Practice Address - Phone:419-447-0398
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.1395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP1395OtherOH LICENSE
OH000000142710OtherANTHEM BLUE CROSS BLUE SH