Provider Demographics
NPI:1295377240
Name:JACKSON, PETRINA (DC)
Entity Type:Individual
Prefix:DR
First Name:PETRINA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17516 E CARRIAGEWAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2079
Mailing Address - Country:US
Mailing Address - Phone:708-914-4445
Mailing Address - Fax:708-260-6699
Practice Address - Street 1:17516 E CARRIAGEWAY DR STE B
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2079
Practice Address - Country:US
Practice Address - Phone:708-260-6699
Practice Address - Fax:708-914-4393
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor