Provider Demographics
NPI:1538560123
Name:JACKSON, JOSEPH RYAN (DC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RYAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1043 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-7011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1043 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-7011
Practice Address - Country:US
Practice Address - Phone:270-999-5708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5435111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor