Provider Demographics
NPI:1801335369
Name:JACKSON, CINDY
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:JACKSON
Suffix:
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 1:20441 BEACONSFIELD ST APT 8
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1372
Mailing Address - Country:US
Mailing Address - Phone:313-850-0946
Mailing Address - Fax:
Practice Address - Street 1:20441 BEACONSFIELD ST APT 8
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1372
Practice Address - Country:US
Practice Address - Phone:313-850-0946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI238015491094374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide