Provider Demographics
NPI:1619583069
Name:JACKSON, JORDAN C (DC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:C
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 1:14 DEPALMA CT
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1675
Mailing Address - Country:US
Mailing Address - Phone:989-444-9719
Mailing Address - Fax:
Practice Address - Street 1:280 US HIGHWAY 9 STE E
Practice Address - Street 2:
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1572
Practice Address - Country:US
Practice Address - Phone:732-617-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00775000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor