Provider Demographics
NPI:1891957015
Name:JACKSON, MARVIN ZEBEDEE JR (BS,DC)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:ZEBEDEE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:BS,DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7435 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1542
Mailing Address - Country:US
Mailing Address - Phone:312-998-8282
Mailing Address - Fax:
Practice Address - Street 1:7435 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1542
Practice Address - Country:US
Practice Address - Phone:312-998-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-29
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor