Provider Demographics
NPI:1477656528
Name:ICKLER, JEFFREY J (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:ICKLER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10241 BONEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-4889
Mailing Address - Country:US
Mailing Address - Phone:228-967-7651
Mailing Address - Fax:228-967-7653
Practice Address - Street 1:10241 BONEY AVE STE A
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-4889
Practice Address - Country:US
Practice Address - Phone:228-967-7651
Practice Address - Fax:228-967-7653
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00022258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009998120Medicaid
AL009998120Medicaid