Provider Demographics
NPI:1962595777
Name:JEAKLE, JAMES (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:JEAKLE
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 1:14700 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1930
Mailing Address - Country:US
Mailing Address - Phone:231-547-4477
Mailing Address - Fax:231-547-4753
Practice Address - Street 1:14700 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1930
Practice Address - Country:US
Practice Address - Phone:231-547-4477
Practice Address - Fax:231-547-4753
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054830207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJJ054830OtherBLUE SHIELD LICENSE
MI4301054830OtherBC LICENSE NUMBER
MI3196127Medicaid
MI4301054830OtherBC LICENSE NUMBER
MIJJ054830OtherBLUE SHIELD LICENSE