Provider Demographics
NPI:1912910316
Name:JACKSON, CHRISTOPHER WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:WILLIAM
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 HUNTERS RIDGE DR
Mailing Address - Street 2:POB 253
Mailing Address - City:LABADIE
Mailing Address - State:MO
Mailing Address - Zip Code:63055-1525
Mailing Address - Country:US
Mailing Address - Phone:314-660-9517
Mailing Address - Fax:
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2394
Practice Address - Country:US
Practice Address - Phone:636-496-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108659146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF72510Medicare UPIN