Healthcare Provider Details

I. General information

NPI: 1235898081
Provider Name (Legal Business Name): CIGNE JACKSON AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CIGNE TORRES AT, ATC

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST
LANSING MI
48912-2306
US

IV. Provider business mailing address

2315 E JOLLY RD APT 6
LANSING MI
48910-8298
US

V. Phone/Fax

Practice location:
  • Phone: 907-750-4002
  • Fax:
Mailing address:
  • Phone: 907-750-4002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002387
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: