Provider Demographics
NPI:1649288317
Name:JACKSON, BRYAN W (DC, PT)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4780
Mailing Address - Country:US
Mailing Address - Phone:860-638-3820
Mailing Address - Fax:860-638-3840
Practice Address - Street 1:410 SAYBROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-638-3820
Practice Address - Fax:860-638-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3372111N00000X
NC9924225100000X
CT005803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor