Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1788 | MN |
NPI | 1285722512 |
---|---|
Provider Name | Dr. Steven Bruce Jackson |
First Address | Shoreview, MN 55126-5002 |
Second Address | Saint Paul, MN 55126-3170 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 15/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
411415294 | (02) | MN |
433527900 | (05) | MN |