Provider Demographics
NPI:1144211657
Name:JACKSON, ROBERT DONALD JR (DC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DONALD
Last Name:JACKSON
Suffix:JR
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 1:12505 W 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5254
Mailing Address - Country:US
Mailing Address - Phone:303-237-9617
Mailing Address - Fax:303-237-6253
Practice Address - Street 1:12505 W 32ND AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5254
Practice Address - Country:US
Practice Address - Phone:303-237-9617
Practice Address - Fax:303-237-6253
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO464338Medicare ID - Type Unspecified
K1503Medicare UPIN