Provider Demographics
NPI:1477007615
Name:JACKSON, CHERYSE
Entity Type:Individual
Prefix:
First Name:CHERYSE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KINGS CROSSING COURT
Mailing Address - Street 2:L
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030
Mailing Address - Country:US
Mailing Address - Phone:443-255-9527
Mailing Address - Fax:
Practice Address - Street 1:12 KINGS CROSSING CT
Practice Address - Street 2:APT L
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-3172
Practice Address - Country:US
Practice Address - Phone:443-255-9527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR204022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily