Provider Demographics
NPI:1134636921
Name:JACKSON, BRIAN JEFFREY (CO, AT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JEFFREY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CO, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 GALTIER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4456
Mailing Address - Country:US
Mailing Address - Phone:651-260-5993
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 10
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3898
Practice Address - Country:US
Practice Address - Phone:651-646-7246
Practice Address - Fax:651-641-0726
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist