Provider Demographics
NPI:1457545113
Name:JACKSON CWYNAR, KIMBERLY J (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:JACKSON CWYNAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3796 DIBBLE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9344
Mailing Address - Country:US
Mailing Address - Phone:517-937-2022
Mailing Address - Fax:
Practice Address - Street 1:2136 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3557
Practice Address - Country:US
Practice Address - Phone:517-750-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKC010406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist