Provider Demographics
NPI:1063696516
Name:JAECKLE, THERESE L (MSN, APNP)
Entity type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:L
Last Name:JAECKLE
Suffix:
Gender:F
Credentials:MSN, APNP
Other - Prefix:MS
Other - First Name:THERESE
Other - Middle Name:ANN
Other - Last Name:LUPONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APNP
Mailing Address - Street 1:4670 N 143RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-1664
Mailing Address - Country:US
Mailing Address - Phone:262-781-0297
Mailing Address - Fax:
Practice Address - Street 1:W62N248 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3319-033363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily