Provider Demographics
NPI:1215022280
Name:JACKSON, CYNTHIA (PSYCH NP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYCH NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6093 S QUEBEC ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4543
Mailing Address - Country:US
Mailing Address - Phone:303-770-6933
Mailing Address - Fax:
Practice Address - Street 1:6093 S QUEBEC ST STE 100
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-4543
Practice Address - Country:US
Practice Address - Phone:303-770-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO176692163WC1500X
CO990052363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71671218Medicaid