Provider Demographics
NPI:1669728101
Name:JACKSON CHIROPRACTIC
Entity type:Organization
Organization Name:JACKSON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-614-0401
Mailing Address - Street 1:1258 BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3771
Mailing Address - Country:US
Mailing Address - Phone:636-614-0401
Mailing Address - Fax:636-614-4111
Practice Address - Street 1:1258 BRYAN RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3771
Practice Address - Country:US
Practice Address - Phone:636-614-0401
Practice Address - Fax:636-614-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty