Provider Demographics
NPI:1124805320
Name:JACKSON, CYNTHIA LEE (LPN)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LEE
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:170 MICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-4731
Mailing Address - Country:US
Mailing Address - Phone:513-460-9828
Mailing Address - Fax:
Practice Address - Street 1:170 MICHAEL AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-4731
Practice Address - Country:US
Practice Address - Phone:513-460-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN129775164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse