Provider Demographics
NPI:1053338665
Name:JACKSON, CYNTHIA (PHD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
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 1:593 EDDY ST
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY APC 12
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4370
Mailing Address - Fax:401-444-8514
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY APC 12
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4370
Practice Address - Fax:401-444-8514
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILS842246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology