Provider Demographics
NPI:1407354509
Name:JACKSON, CHADWICK THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:CHADWICK
Middle Name:THOMAS
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 1:205 CHAMPION WAY STE 9
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8862
Mailing Address - Country:US
Mailing Address - Phone:615-516-5194
Mailing Address - Fax:
Practice Address - Street 1:205 CHAMPION WAY STE 9
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8862
Practice Address - Country:US
Practice Address - Phone:615-516-5194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5563OtherLICENSE NUMBER