Provider Demographics
NPI:1891013405
Name:JACKSON, BRIAN MATTHEW (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 HAWTHORNE DR
Mailing Address - Street 2:STE 400
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2814
Mailing Address - Country:US
Mailing Address - Phone:765-894-0500
Mailing Address - Fax:317-454-1327
Practice Address - Street 1:1620 HAWTHORNE DR
Practice Address - Street 2:STE 400
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2814
Practice Address - Country:US
Practice Address - Phone:765-894-0500
Practice Address - Fax:317-454-1327
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002510A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200990510Medicaid