Provider Demographics
NPI:1831298165
Name:JAECK, GREGORY ALAN
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:JAECK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:ALAN
Other - Last Name:JAECK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-0002
Mailing Address - Country:US
Mailing Address - Phone:530-677-6711
Mailing Address - Fax:
Practice Address - Street 1:7700 FOLSOM BLVD.
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-386-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG421152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G421150Medicare ID - Type UnspecifiedMEDICARE
CAA48821Medicare UPIN