Provider Demographics
NPI:1386015121
Name:JACKSON, AMY (DC)
Entity Type:Individual
Prefix:DR
First Name:AMY
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 1:826 CAMINO DE MONTE REY
Mailing Address - Street 2:A3
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3977
Mailing Address - Country:US
Mailing Address - Phone:500-598-8963
Mailing Address - Fax:505-988-9723
Practice Address - Street 1:826 CAMINO DE MONTE REY
Practice Address - Street 2:A3
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3977
Practice Address - Country:US
Practice Address - Phone:500-598-8963
Practice Address - Fax:505-988-9723
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor