Provider Demographics
NPI:1669085718
Name:JACKSON, KYLE SEBASTIAN (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:SEBASTIAN
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 1:12620 BEACH BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7130
Mailing Address - Country:US
Mailing Address - Phone:904-645-0777
Mailing Address - Fax:904-645-3483
Practice Address - Street 1:12620 BEACH BLVD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7130
Practice Address - Country:US
Practice Address - Phone:904-645-0777
Practice Address - Fax:904-645-3483
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH13208OtherSTATE LICENSE