Provider Demographics
NPI:1720614837
Name:JACKSON, CHRISTIAN TYLER
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:TYLER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W STE C102
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5670
Mailing Address - Country:US
Mailing Address - Phone:704-821-5000
Mailing Address - Fax:
Practice Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W STE C102
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5670
Practice Address - Country:US
Practice Address - Phone:704-821-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor