Healthcare Provider Details

I. General information

NPI: 1104993187
Provider Name (Legal Business Name): SANDY N JACKSON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7049 HIGHWAY BB
CEDAR HILL MO
63016-2343
US

IV. Provider business mailing address

1303 HAVENHURST RD
MANCHESTER MO
63011-4404
US

V. Phone/Fax

Practice location:
  • Phone: 636-247-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2004023382
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38010239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: