Healthcare Provider Details

I. General information

NPI: 1326353368
Provider Name (Legal Business Name): CYNTHIA CRISTIN JACKSON L.P.C., N.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2010
Last Update Date: 08/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 COACH RD
REIDSVILLE NC
27320-5536
US

IV. Provider business mailing address

334 IRVIN ST
REIDSVILLE NC
27320-3648
US

V. Phone/Fax

Practice location:
  • Phone: 336-349-2233
  • Fax:
Mailing address:
  • Phone: 336-932-3348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8079
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: