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General NPI Number Information
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NPI Number | 1669728101
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Entity Type | Organization
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Legal Business Name | JACKSON CHIROPRACTIC
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 09/21/2012
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Provider Practice Location Address
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Address Line | 1258 BRYAN RD
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City | O FALLON
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State | MO
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Zip | 63366-3771
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Country | US
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Telephone | 636-614-0401
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Fax | 636-614-4111
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Provider Business Mailing Address
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Address Line | 1258 BRYAN RD
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City | O FALLON
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State | MO
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Zip | 63366-3771
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Country | US
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Telephone | 636-614-0401
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Fax | 636-614-4111
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. GARRETT RODNEY JACKSON
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Credential | D.C.
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Telephone | 636-614-0401
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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 | 2012014933
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License Number State | MO
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