Provider Demographics
NPI:1114386620
Name:JACKSON, JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:5801 S FASHION BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6159
Mailing Address - Country:US
Mailing Address - Phone:801-923-2882
Mailing Address - Fax:801-506-0134
Practice Address - Street 1:5801 S FASHION BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-923-2882
Practice Address - Fax:801-506-0134
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9690256-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic