Provider Demographics
NPI:1780171413
Name:TRAXLER, JAKE MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:MICHAEL
Last Name:TRAXLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HENNEPIN AVE N
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-1416
Mailing Address - Country:US
Mailing Address - Phone:320-864-3121
Mailing Address - Fax:
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine