Provider Demographics
NPI:1508828054
Name:JAECKEL, KERRITH LYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRITH
Middle Name:LYN
Last Name:JAECKEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1950
Mailing Address - Fax:704-384-1955
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PL
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3671
Practice Address - Country:US
Practice Address - Phone:704-384-1950
Practice Address - Fax:704-384-1955
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9700294208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00295Medicaid
NC891050RMedicaid
NC891050RMedicaid
NCG22836Medicare UPIN