Provider Demographics
NPI:1205154036
Name:JACKSON, LANCE DUANE (DC)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:DUANE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 BROADWAY ST STE B
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-3954
Mailing Address - Country:US
Mailing Address - Phone:281-485-5051
Mailing Address - Fax:
Practice Address - Street 1:4616 BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-3954
Practice Address - Country:US
Practice Address - Phone:832-651-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor