Basic Information
| Provider Information | |||||||||
| NPI: | 1649288317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C., P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SAYBROOK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383840 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 SAYBROOK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3372 | NC | N | Chiropractic Providers | Chiropractor | 225100000X | 9924 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 005803 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.