Provider Demographics
NPI:1053321877
Name:JACKSON, NATHAN W (DC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:W
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:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-0131
Mailing Address - Country:US
Mailing Address - Phone:920-834-7034
Mailing Address - Fax:920-834-2844
Practice Address - Street 1:1134 MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1540
Practice Address - Country:US
Practice Address - Phone:920-834-7034
Practice Address - Fax:920-834-2844
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230100-8172111N00000X
WI3687-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI144266436Medicaid
WI38929400Medicaid
MION22100Medicare ID - Type Unspecified