Provider Demographics
NPI:1619996493
Name:JACKS, DEAN C (DC)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:C
Last Name:JACKS
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 1:1550 JOHN SIMS PKWY E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2138
Mailing Address - Country:US
Mailing Address - Phone:850-678-8048
Mailing Address - Fax:855-333-8662
Practice Address - Street 1:1550 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2138
Practice Address - Country:US
Practice Address - Phone:850-678-8048
Practice Address - Fax:855-333-8662
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL350046350OtherRAILROAD MEDICARE
FL55486OtherBLUE CROSS BLUE SHIELD
FLU74540Medicare UPIN
FL55486ZMedicare PIN