Provider Demographics
NPI:1376249516
Name:CLEMENTS, JACKSON DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:DALE
Last Name:CLEMENTS
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 1:14751 OUTLOOK ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-1182
Mailing Address - Country:US
Mailing Address - Phone:913-568-6287
Mailing Address - Fax:
Practice Address - Street 1:12631 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1701
Practice Address - Country:US
Practice Address - Phone:913-685-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-02-11
Deactivation Date:2023-02-03
Deactivation Code:
Reactivation Date:2023-02-11
Provider Licenses
StateLicense IDTaxonomies
KS01-06246111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor