Provider Demographics
NPI:1568519577
Name:JACKSON, ERICA LEA (DC)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LEA
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 1:624 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2904
Mailing Address - Country:US
Mailing Address - Phone:218-822-3855
Mailing Address - Fax:218-822-3854
Practice Address - Street 1:13968 CYPRESS DR STE 1B
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-5904
Practice Address - Country:US
Practice Address - Phone:218-822-3855
Practice Address - Fax:218-822-3854
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN088450200Medicaid