Provider Demographics
NPI:1396866406
Name:MACK, JACKIE J
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:J
Last Name:MACK
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 1:807 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-2907
Mailing Address - Country:US
Mailing Address - Phone:412-731-7234
Mailing Address - Fax:
Practice Address - Street 1:712 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15221-2940
Practice Address - Country:US
Practice Address - Phone:412-243-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator