Provider Demographics
NPI:1730361312
Name:JACKSON, CYNTHIA DARLEEN (PHD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:DARLEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 PATTERSON ST
Mailing Address - Street 2:STE 504
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2120
Mailing Address - Country:US
Mailing Address - Phone:615-977-8779
Mailing Address - Fax:615-982-6932
Practice Address - Street 1:1916 PATTERSON ST
Practice Address - Street 2:STE 504
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2120
Practice Address - Country:US
Practice Address - Phone:615-977-8779
Practice Address - Fax:615-982-6932
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist