Provider Demographics
NPI:1588922934
Name:JACKSON, CYNTHIA DIANE (LPN)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 CAMDEN WAY
Mailing Address - Street 2:UNIT B
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6850
Mailing Address - Country:US
Mailing Address - Phone:262-408-2606
Mailing Address - Fax:
Practice Address - Street 1:1315 CAMDEN WAY
Practice Address - Street 2:UNIT B
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-6850
Practice Address - Country:US
Practice Address - Phone:262-408-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305199-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse