Provider Demographics
NPI:1225650757
Name:JACKSON, CYNTHIA LINNEA (LM, CPM)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:LINNEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LM, CPM
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 5364
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48090-5364
Mailing Address - Country:US
Mailing Address - Phone:313-971-7324
Mailing Address - Fax:586-777-5874
Practice Address - Street 1:20551 MOTOR DR APT A4
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1831
Practice Address - Country:US
Practice Address - Phone:313-971-7324
Practice Address - Fax:586-777-5874
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7601000052176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty