Healthcare Provider Details

I. General information

NPI: 1164594867
Provider Name (Legal Business Name): JACKSON CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CAMERON PARK DR STE 200
CAMERON PARK CA
95682-7652
US

IV. Provider business mailing address

3330 CAMERON PARK DR STE 200
CAMERON PARK CA
95682-7652
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-4803
  • Fax: 530-621-2450
Mailing address:
  • Phone: 530-621-4803
  • Fax: 530-621-2450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number20634
License Number StateCA

VIII. Authorized Official

Name: DR. GARRELL KEITHE JACKSON
Title or Position: PRESIDENT
Credential: D.C.
Phone: 530-621-4803