Provider Demographics
NPI:1376021691
Name:CASSAGNOL, JACKSIS (CNM)
Entity Type:Individual
Prefix:
First Name:JACKSIS
Middle Name:
Last Name:CASSAGNOL
Suffix:
Gender:F
Credentials:CNM
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 528
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-0528
Mailing Address - Country:US
Mailing Address - Phone:606-672-2312
Mailing Address - Fax:
Practice Address - Street 1:195 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-4601
Practice Address - Country:US
Practice Address - Phone:606-672-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACNM04524176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife