Provider Demographics
NPI:1922367515
Name:JACKSON, GARRETT RODNEY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:RODNEY
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 1:138 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63390-3393
Mailing Address - Country:US
Mailing Address - Phone:636-485-2077
Mailing Address - Fax:
Practice Address - Street 1:1258 BRYAN RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3771
Practice Address - Country:US
Practice Address - Phone:636-614-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor