Provider Demographics
NPI:1114111572
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:CHARLES
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-695-4090
Mailing Address - Street 1:2455 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5063
Mailing Address - Country:US
Mailing Address - Phone:810-695-4090
Mailing Address - Fax:810-695-6690
Practice Address - Street 1:2455 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5063
Practice Address - Country:US
Practice Address - Phone:810-695-4090
Practice Address - Fax:810-695-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301003001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B55096Medicare PIN