Provider Demographics
NPI:1588999296
Name:JACKSON, SHAUN CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:CHARLES
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 1:2406 PRINCESS ANNE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3409
Mailing Address - Country:US
Mailing Address - Phone:757-351-3778
Mailing Address - Fax:757-689-2551
Practice Address - Street 1:2406 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3409
Practice Address - Country:US
Practice Address - Phone:757-351-3778
Practice Address - Fax:757-689-2551
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556741111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor