Provider Demographics
NPI:1962528737
Name:JACKSON, CYNTHIA M
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:M
Other - Last Name:MOURAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16016 BERRY LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5631
Mailing Address - Country:US
Mailing Address - Phone:586-247-1178
Mailing Address - Fax:
Practice Address - Street 1:13745 19 MILE
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-247-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N64560Medicare PIN