Provider Demographics
NPI:1548478217
Name:JACKSON, CHERYL R (M S, AT, C)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:M S, AT, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5243 DALEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1748
Mailing Address - Country:US
Mailing Address - Phone:304-776-6220
Mailing Address - Fax:
Practice Address - Street 1:5243 DALEWOOD DR
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1748
Practice Address - Country:US
Practice Address - Phone:304-776-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF1271642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer