Provider Demographics
NPI:1104133867
Name:JAECKS, CARISSA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:MARIE
Last Name:JAECKS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:CARISSA
Other - Middle Name:MARIE JAECKS
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:702 EISENHOWER DR
Mailing Address - Street 2:STE G
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-2152
Mailing Address - Country:US
Mailing Address - Phone:715-281-4179
Mailing Address - Fax:
Practice Address - Street 1:1620 N SHAWANO ST
Practice Address - Street 2:STE E
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-9318
Practice Address - Country:US
Practice Address - Phone:920-982-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4599-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor