Provider Demographics
NPI:1144207556
Name:JACKSON, MICHAEL WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 W KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1229
Mailing Address - Country:US
Mailing Address - Phone:417-831-7575
Mailing Address - Fax:417-831-7632
Practice Address - Street 1:733 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1229
Practice Address - Country:US
Practice Address - Phone:417-831-7575
Practice Address - Fax:417-831-7632
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004027940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208658OtherBLUE CROSS BLUE SHIELD
MO9422836OtherPHCS
MO5687508OtherFIRST HEALTH
MO7483792OtherAETNA