Provider Demographics
NPI:1215343553
Name:JAECKLEIN, FREDERICK JOHN (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOHN
Last Name:JAECKLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:901-478-0954
Mailing Address - Fax:901-478-0951
Practice Address - Street 1:1211 UNION AVE STE 300
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6655
Practice Address - Country:US
Practice Address - Phone:901-272-6018
Practice Address - Fax:901-201-4203
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN637332086S0129X
MI43010950372086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery