MEDICARE: DR. GARRELL KEITHE JACKSON DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	20634	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC0206340	OTHER		BLUE SHEILD
2	ZZZ61178Z	OTHER		BLUE SHEILD

General Provider Information

NPI Number	:	1326043399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARRELL KEITHE JACKSON DC

Provider Business Mailing Address
First Line	:	4535 MISSOURI FLAT RD
Second Line	:	STE 1E
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-6808
Country	:	US
Telephone Number	:	530-621-4803
Fax Number	:	530-621-2450

Provider Business Practice Location Address
First Line	:	3330 CAMERON PARK DR STE 200
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-7652
Country	:	US
Telephone Number	:	530-621-4803
Fax Number	:	530-621-2450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	05/05/2021

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