Provider Demographics
NPI:1255734331
Name:JACKSON, CYNTHIA R
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3173 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-2178
Mailing Address - Country:US
Mailing Address - Phone:225-778-7678
Mailing Address - Fax:225-341-6825
Practice Address - Street 1:3173 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-2178
Practice Address - Country:US
Practice Address - Phone:225-778-7678
Practice Address - Fax:225-341-6825
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX251B00000XOtherPLPC
LA101Y00000XOtherPLPC