Provider Demographics
NPI:1326043399
Name:JACKSON, GARRELL KEITHE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARRELL
Middle Name:KEITHE
Last Name:JACKSON
Suffix:
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 1:4535 MISSOURI FLAT RD
Mailing Address - Street 2:STE 1E
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6808
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20634111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0206340OtherBLUE SHEILD
ZZZ61178ZOtherBLUE SHEILD
DC0206340OtherBLUE SHEILD
U22684Medicare ID - Type Unspecified