Provider Demographics
NPI:1134874886
Name:JAECKLE, HEIDI (EDD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:JAECKLE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6118 MONTMORENCY DR SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8059
Mailing Address - Country:US
Mailing Address - Phone:518-669-6034
Mailing Address - Fax:
Practice Address - Street 1:4081 CASCADE RD SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2170
Practice Address - Country:US
Practice Address - Phone:616-319-1978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451020894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional