Provider Demographics
NPI:1558304386
Name:JACKSON, NEIL BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:BRADLEY
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:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MI
Mailing Address - Zip Code:49621-0173
Mailing Address - Country:US
Mailing Address - Phone:231-228-5233
Mailing Address - Fax:231-228-5232
Practice Address - Street 1:9093 S. KASSON ST
Practice Address - Street 2:
Practice Address - City:CEDAR
Practice Address - State:MI
Practice Address - Zip Code:49621
Practice Address - Country:US
Practice Address - Phone:231-228-5233
Practice Address - Fax:231-228-5232
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P31020Medicare ID - Type Unspecified