Provider Demographics
NPI:1053142588
Name:JACKSON, CYNTHIA 'KAYLA'
Entity type:Individual
Prefix:
First Name:CYNTHIA 'KAYLA'
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 S INDUSTRIAL HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6791
Mailing Address - Country:US
Mailing Address - Phone:734-203-0181
Mailing Address - Fax:
Practice Address - Street 1:314 E CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-2876
Practice Address - Country:US
Practice Address - Phone:989-278-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician