Provider Demographics
NPI:1194388678
Name:JACKSON, MARY SHEREE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SHEREE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15210-3312
Mailing Address - Country:US
Mailing Address - Phone:412-961-4070
Mailing Address - Fax:
Practice Address - Street 1:226 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15210-3312
Practice Address - Country:US
Practice Address - Phone:412-961-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39723601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39723601Medicaid