Provider Demographics
NPI:1972179018
Name:JACKSON, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 S FULTON AVE UNIT 1411
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354-1770
Mailing Address - Country:US
Mailing Address - Phone:424-284-9663
Mailing Address - Fax:
Practice Address - Street 1:3640 S FULTON AVE UNIT 1411
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-1770
Practice Address - Country:US
Practice Address - Phone:424-284-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor