Provider Demographics
NPI:1972830313
Name:JACKSON, BENJAMIN CALEB (DC)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:CALEB
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 1:522 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1517
Mailing Address - Country:US
Mailing Address - Phone:307-532-2225
Mailing Address - Fax:307-534-2202
Practice Address - Street 1:522 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1517
Practice Address - Country:US
Practice Address - Phone:307-532-2225
Practice Address - Fax:307-534-2202
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor