Basic Information
| Provider Information | |||||||||
| NPI: | 1902858483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAEGER | ||||||||
| FirstName: | MARCELLA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 203 BAURER CIR | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956306775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167430968 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4062 FLYING C RD | ||||||||
| Address2: | |||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956829664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306768230 | ||||||||
| FaxNumber: | 5306760819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G87379 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2000148102 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-101304 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18516 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G87379 | 05 | CA | MEDICAID | 18516 | 01 | AL | STATE LICENSE | OTHER | 2000148102 | 01 | MO | STATE LICENSE | OTHER | BJ6571980 | 01 | CA | DEA | OTHER | 036-101304 | 01 | IL | STATE LICENSE | OTHER | G87379 | 01 | CA | STATE LICENSE | OTHER |