Provider Demographics
NPI:1104986793
Name:JACKSON, KELLY A (DC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
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 1:190 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760
Mailing Address - Country:US
Mailing Address - Phone:508-651-2646
Mailing Address - Fax:508-655-6650
Practice Address - Street 1:190 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:508-651-2646
Practice Address - Fax:508-655-6650
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1797111N00000X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36275OtherBCBS
MAY39303OtherGROUP # BCBS
MAY36275Medicare UPIN