Provider Demographics
NPI:1780665539
Name:JACKSON, RYAN DANIEL (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DANIEL
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 1:1261 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3034
Mailing Address - Country:US
Mailing Address - Phone:814-336-5420
Mailing Address - Fax:814-336-2898
Practice Address - Street 1:324 13TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-1367
Practice Address - Country:US
Practice Address - Phone:814-437-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor