Provider Demographics
NPI:1578806840
Name:JAEGER, JACLYN SUSAN (DO)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:SUSAN
Last Name:JAEGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JACLYN
Other - Middle Name:SUSAN
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:GRADUATE MEDICAL EDUCATION - LM068
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1921
Mailing Address - Country:US
Mailing Address - Phone:860-679-6296
Mailing Address - Fax:860-679-4613
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION - LM068
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1921
Practice Address - Country:US
Practice Address - Phone:860-679-6296
Practice Address - Fax:860-679-4613
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT056802207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program