Provider Demographics
NPI:1417107947
Name:JACKSON, CHRISTOPHER L (PHD, DOM, AP)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD, DOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 4TH ST N STE 312
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4313
Mailing Address - Country:US
Mailing Address - Phone:727-329-9637
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 312
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-329-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-20
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X, 175L00000X
FLAP0002609171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath
No175L00000XOther Service ProvidersHomeopath