Provider Demographics
NPI:1598010431
Name:JACKMAN, RUSSELL (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:JACKMAN
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 2638
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-2638
Mailing Address - Country:US
Mailing Address - Phone:501-960-3292
Mailing Address - Fax:
Practice Address - Street 1:524 W DAISY L GATSON BATES DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-4816
Practice Address - Country:US
Practice Address - Phone:501-960-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor