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General NPI Number Information
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NPI Number | 1578896031
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Entity Type | Individual
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Provider Name | BRANDON T. JACKSON D.C.
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Gender | Male
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Dates
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Enumeration Date | 09/15/2009
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Last Update Date | 04/02/2022
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Provider Practice Location Address
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Address Line | 5551 WINGHAVEN BLVD STE 20
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City | O FALLON
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State | MO
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Zip | 63368-3618
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Country | US
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Telephone | 636-614-0401
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Fax | 636-265-0014
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Provider Business Mailing Address
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Address Line | 5551 WINGHAVEN BLVD STE 20
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City | O FALLON
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State | MO
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Zip | 63368-3618
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Country | US
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Telephone | 636-614-0401
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Fax | 636-265-0014
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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 | 2011014558
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License Number State | MO
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