Provider Demographics
NPI:1164594867
Name:JACKSON CHIROPRACTIC INC
Entity Type:Organization
Organization Name:JACKSON CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRELL
Authorized Official - Middle Name:KEITHE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-621-4803
Mailing Address - Street 1:3330 CAMERON PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-7652
Mailing Address - Country:US
Mailing Address - Phone:530-621-4803
Mailing Address - Fax:530-621-2450
Practice Address - Street 1:3330 CAMERON PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-7652
Practice Address - Country:US
Practice Address - Phone:530-621-4803
Practice Address - Fax:530-621-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20634111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO206340OtherBLUE SHIELD PROVIDER #
CAZZZ61178ZOtherBLUE SHIELD
CAZZZ61178ZOtherBLUE SHIELD