Provider Demographics
NPI:1598724536
Name:JACKSON, CECILIA T (CNM)
Entity Type:Individual
Prefix:MRS
First Name:CECILIA
Middle Name:T
Last Name:JACKSON
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 1:5301 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2805
Mailing Address - Country:US
Mailing Address - Phone:520-795-8188
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-795-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10474367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ308506Medicaid
FL003066700Medicaid