Provider Demographics
NPI:1053086082
Name:BATES, JACKSON (DC)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:BATES
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 1:8354 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4313
Mailing Address - Country:US
Mailing Address - Phone:818-687-0734
Mailing Address - Fax:
Practice Address - Street 1:8354 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4313
Practice Address - Country:US
Practice Address - Phone:323-831-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor