Provider Demographics
NPI:1609065861
Name:JACKSON, CYNTHIA ANN (LCSW-R,CASAC,CEAP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-R,CASAC,CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6680 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5933
Mailing Address - Country:US
Mailing Address - Phone:716-631-9212
Mailing Address - Fax:
Practice Address - Street 1:6680 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5933
Practice Address - Country:US
Practice Address - Phone:716-631-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0527061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11515193OtherUNIVERA HEALTHCARE