Provider Demographics
NPI:1093289795
Name:JACKSON, MATTHEW KORY (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KORY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E 4500 S STE G230
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4510
Mailing Address - Country:US
Mailing Address - Phone:385-743-8833
Mailing Address - Fax:
Practice Address - Street 1:515 E 4500 S STE G230
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-4510
Practice Address - Country:US
Practice Address - Phone:385-743-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10228975-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor