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General NPI Number Information
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NPI Number | 1922367515
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Entity Type | Individual
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Provider Name | GARRETT RODNEY JACKSON D.C.
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Gender | Male
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Dates
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Enumeration Date | 05/16/2012
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Last Update Date | 08/02/2012
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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 |
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Provider Business Mailing Address
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Address Line | 138 QUAIL CREEK DR
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City | WRIGHT CITY
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State | MO
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Zip | 63390-3393
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Country | US
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Telephone | 636-485-2077
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Fax |
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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 | 2012014933
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License Number State | MO
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