Provider Demographics
NPI:1922752286
Name:JACKSON, MARILYN MORAN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:MORAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-2835
Mailing Address - Country:US
Mailing Address - Phone:615-396-8482
Mailing Address - Fax:
Practice Address - Street 1:611 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2835
Practice Address - Country:US
Practice Address - Phone:615-396-8482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000003468OtherTN CHIROPRACTIC PHYSICIAN LICENSE NUMBER