Provider Demographics
NPI:1073662680
Name:JACKSON CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:JACKSON CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-330-6655
Mailing Address - Street 1:3801 S BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5479
Mailing Address - Country:US
Mailing Address - Phone:405-330-6655
Mailing Address - Fax:405-340-3531
Practice Address - Street 1:3801 S BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5479
Practice Address - Country:US
Practice Address - Phone:405-330-6655
Practice Address - Fax:405-340-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty