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General NPI Number Information
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NPI Number | 1053321877
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Entity Type | Individual
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Provider Name | NATHAN W JACKSON DC
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Gender | Male
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 09/01/2021
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Provider Practice Location Address
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Address Line | 1134 MAIN ST
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City | OCONTO
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State | WI
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Zip | 54153-1540
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Country | US
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Telephone | 920-834-7034
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Fax | 920-834-2844
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Provider Business Mailing Address
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Address Line | PO BOX 131
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City | OCONTO
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State | WI
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Zip | 54153-0131
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Country | US
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Telephone | 920-834-7034
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Fax | 920-834-2844
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 230100-8172
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3687-12
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License Number State | WI
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