Provider Demographics
NPI:1932722568
Name:HENNING, JACKSON TIMOTHY (DC)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:TIMOTHY
Last Name:HENNING
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 1:203 AMICKS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8663
Mailing Address - Country:US
Mailing Address - Phone:803-932-9399
Mailing Address - Fax:
Practice Address - Street 1:203 AMICKS FERRY RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8663
Practice Address - Country:US
Practice Address - Phone:803-932-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor