Provider Demographics
NPI:1932978764
Name:JAECKLE, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JAECKLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 STOUGHTON LN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2086
Mailing Address - Country:US
Mailing Address - Phone:716-481-9044
Mailing Address - Fax:
Practice Address - Street 1:145 STOUGHTON LN
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2086
Practice Address - Country:US
Practice Address - Phone:716-481-9044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010785-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist