Provider Demographics
NPI:1982735536
Name:JACKSON CHIROPRACTIC PC
Entity Type:Organization
Organization Name:JACKSON CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-351-7746
Mailing Address - Street 1:2912 CROSSING COURT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6163
Mailing Address - Country:US
Mailing Address - Phone:217-351-7746
Mailing Address - Fax:662-042-7748
Practice Address - Street 1:2912 CROSSING COURT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6163
Practice Address - Country:US
Practice Address - Phone:217-351-7746
Practice Address - Fax:866-204-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010337111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty