Provider Demographics
NPI:1730850850
Name:JACKSON, TREVOR GLENN (DC)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:GLENN
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 1:990 MEDICAL DR STE UL1
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4714
Mailing Address - Country:US
Mailing Address - Phone:435-723-2311
Mailing Address - Fax:
Practice Address - Street 1:1986 N HILL FIELD RD STE 7A
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2112
Practice Address - Country:US
Practice Address - Phone:801-820-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12458426-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor