Provider Demographics
NPI:1861864662
Name:JAECKELS, NICOLE L (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:JAECKELS
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:VAN ALSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1516 HILLTOP LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-2008
Mailing Address - Country:US
Mailing Address - Phone:920-254-3323
Mailing Address - Fax:
Practice Address - Street 1:1516 HILLTOP LN
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-2008
Practice Address - Country:US
Practice Address - Phone:920-254-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI190599-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse