Provider Demographics
NPI:1801404959
Name:JACKSON, CHEYENNE L I
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:L
Last Name:JACKSON
Suffix:I
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 1:1290 ROCKLEDGE BLVD FL 32955
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 FREEVILLE RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-9684
Practice Address - Country:US
Practice Address - Phone:607-844-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health