Provider Demographics
NPI:1407823958
Name:JACK, KERRI A (PA)
Entity Type:Individual
Prefix:MS
First Name:KERRI
Middle Name:A
Last Name:JACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LYNN ANN DR
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-9382
Mailing Address - Country:US
Mailing Address - Phone:724-882-3082
Mailing Address - Fax:
Practice Address - Street 1:5115 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1301
Practice Address - Country:US
Practice Address - Phone:412-647-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002234L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP55467Medicare UPIN
PA056159Medicare PIN