Provider Demographics
NPI:1235185653
Name:JACKSON, CYNTHIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 N EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1403
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:626-577-8978
Practice Address - Street 1:447 N EL MOLINO AVE
Practice Address - Street 2:#2
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1403
Practice Address - Country:US
Practice Address - Phone:626-577-8480
Practice Address - Fax:626-577-8978
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14155103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP14155AMedicare UPIN