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NPI Code Detail

MEDICARE: KELLY JACKSON PA-C

MEDICARE: KELLY JACKSON PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1619457926
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY JACKSON PA-C
Provider Business Mailing Address
First Line : 884 MAPLE SHADE RD
Second Line :
City : CRANBERRY
State : PA
Zip : 16319-3318
Country : US
Telephone Number : 412-512-0798
Fax Number :
Provider Business Practice Location Address
First Line : 12300 MCCRACKEN RD
Second Line :
City : GARFIELD HEIGHTS
State : OH
Zip : 44125-2975
Country : US
Telephone Number : 412-512-0798
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2018
Last Update Date : 08/16/2018

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