Provider Demographics
NPI:1861445413
Name:JAECKLE, WALTER R I (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:JAECKLE
Suffix:I
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65-1235 OPELO RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8454
Mailing Address - Country:US
Mailing Address - Phone:808-885-1045
Mailing Address - Fax:808-885-1045
Practice Address - Street 1:65-1235 OPELO RD
Practice Address - Street 2:SUITE 1
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8454
Practice Address - Country:US
Practice Address - Phone:808-885-1045
Practice Address - Fax:808-885-1045
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 116103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00402265Medicaid
HI00402265Medicaid