Provider Demographics
NPI:1407558539
Name:JACKO-WISE, CYNTHIA (LCMHCA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JACKO-WISE
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8931 COMMONS TOWNES DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8084
Mailing Address - Country:US
Mailing Address - Phone:337-852-8373
Mailing Address - Fax:
Practice Address - Street 1:8931 COMMONS TOWNES DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8084
Practice Address - Country:US
Practice Address - Phone:337-852-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-17431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health