Provider Demographics
NPI:1891405528
Name:JACKSON, CYNETHIA (LPN)
Entity type:Individual
Prefix:
First Name:CYNETHIA
Middle Name:
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 1:4131 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-8154
Mailing Address - Country:US
Mailing Address - Phone:574-320-0728
Mailing Address - Fax:
Practice Address - Street 1:4131 BASSWOOD DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-8154
Practice Address - Country:US
Practice Address - Phone:574-320-0728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker