Provider Demographics
NPI:1659419075
Name:JACKSON, COREY LAMONT SR (DC)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:LAMONT
Last Name:JACKSON
Suffix:SR
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 1:3615 W HEPBURN ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-2537
Mailing Address - Country:US
Mailing Address - Phone:870-692-6618
Mailing Address - Fax:870-540-0554
Practice Address - Street 1:1518 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-6249
Practice Address - Country:US
Practice Address - Phone:870-535-4878
Practice Address - Fax:870-850-0199
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1684111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A242Medicare ID - Type Unspecified
ARV12243Medicare UPIN