Provider Demographics
NPI:1942441126
Name:JACKSON, CHRISTOPHER W (ATC, CEAS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:ATC, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 VAN BUREN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-3567
Mailing Address - Country:US
Mailing Address - Phone:207-498-1618
Mailing Address - Fax:207-498-1653
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:207-498-1618
Practice Address - Fax:207-498-1653
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer