Provider Demographics
NPI:1285657429
Name:JACKSON, CYNTHIA BERNOUDY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:BERNOUDY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 LAKE SALVADOR DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-5151
Mailing Address - Country:US
Mailing Address - Phone:504-368-3163
Mailing Address - Fax:504-454-5067
Practice Address - Street 1:118 TERRY PKWY
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-2523
Practice Address - Country:US
Practice Address - Phone:504-368-7132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA33751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical