Provider Demographics
NPI:1467837591
Name:JACKSON, BLAKE (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
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 1:8132 CORDOVA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-6005
Mailing Address - Country:US
Mailing Address - Phone:901-751-0939
Mailing Address - Fax:901-751-0332
Practice Address - Street 1:8132 CORDOVA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-6005
Practice Address - Country:US
Practice Address - Phone:901-751-0939
Practice Address - Fax:901-751-0332
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor