Provider Demographics
NPI:1982805180
Name:JAICKS, JEFREY RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFREY
Middle Name:RUSSELL
Last Name:JAICKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 W COSHOCTON ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-1108
Mailing Address - Country:US
Mailing Address - Phone:740-967-1444
Mailing Address - Fax:740-967-2610
Practice Address - Street 1:171 W COSHOCTON ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-1108
Practice Address - Country:US
Practice Address - Phone:740-967-1444
Practice Address - Fax:740-967-2610
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1548323389OtherTYPE II