Provider Demographics
NPI:1063274397
Name:JACKEMEYER, CYNTHIA ANNE
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANNE
Last Name:JACKEMEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CYNTHIA
Other - Middle Name:ANNE
Other - Last Name:EASTLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:522 THURSTON CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1152
Mailing Address - Country:US
Mailing Address - Phone:570-419-3935
Mailing Address - Fax:
Practice Address - Street 1:7125 HANNA ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-1166
Practice Address - Country:US
Practice Address - Phone:260-447-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010511A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist