Healthcare Provider Details

I. General information

NPI: 1285722512
Provider Name (Legal Business Name): STEVEN BRUCE JACKSON D.C, D.A.B.C.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 RICE ST
SAINT PAUL MN
55126-3170
US

IV. Provider business mailing address

3508 RICE ST
SHOREVIEW MN
55126-5002
US

V. Phone/Fax

Practice location:
  • Phone: 651-483-4321
  • Fax: 651-483-3440
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1788
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: