Provider Demographics
NPI:1417440686
Name:JACKSON, KELSEY LYNEE (DOCTOR CHIROPRACTIC)
Entity Type:Individual
Prefix:MISS
First Name:KELSEY
Middle Name:LYNEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DOCTOR CHIROPRACTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 1/2 W BRISTOL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2812
Mailing Address - Country:US
Mailing Address - Phone:937-216-0100
Mailing Address - Fax:
Practice Address - Street 1:1904 1/2 W BRISTOL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2812
Practice Address - Country:US
Practice Address - Phone:937-216-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor