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General NPI Number Information
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NPI Number | 1144718172
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Entity Type | Organization
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Legal Business Name | C MICHAELA JACKS LLC
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Dates
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Enumeration Date | 04/25/2018
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Last Update Date | 05/01/2018
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Provider Practice Location Address
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Address Line | 1789 S BRADDOCK AVE STE 350
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City | PITTSBURGH
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State | PA
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Zip | 15218-1871
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Country | US
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Telephone | 412-213-8425
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Fax |
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Provider Business Mailing Address
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Address Line | 1789 S BRADDOCK AVE STE 350
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City | PITTSBURGH
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State | PA
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Zip | 15218-1871
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Country | US
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Telephone | 412-213-8425
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | CRYSTAL M JACKS
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Credential | LMFT
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Telephone | 412-213-8425
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | MF000999
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License Number State | PA
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