Provider Demographics
NPI:1669446720
Name:JACKSON, JOHN WARREN (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WARREN
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 1:306 HONOR WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-6280
Mailing Address - Country:US
Mailing Address - Phone:256-325-0220
Mailing Address - Fax:
Practice Address - Street 1:4072 SULLIVAN ST
Practice Address - Street 2:SUITE D
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1732
Practice Address - Country:US
Practice Address - Phone:256-464-9067
Practice Address - Fax:256-464-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU85811Medicare UPIN
AL51506707Medicare ID - Type Unspecified