Provider Demographics
NPI:1013062488
Name:JACKSON, REBECCA R (DC)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2740 BRUNSWICK AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1819
Mailing Address - Country:US
Mailing Address - Phone:651-343-0171
Mailing Address - Fax:763-785-4172
Practice Address - Street 1:12203 ABERDEEN ST NE STE 140
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4719
Practice Address - Country:US
Practice Address - Phone:763-785-4120
Practice Address - Fax:763-785-4172
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4292111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation