Provider Demographics
NPI:1548158082
Name:JACKSON, DISSO
Entity type:Individual
Prefix:MR
First Name:DISSO
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 MCKNIGHT EAST DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-6423
Mailing Address - Country:US
Mailing Address - Phone:412-926-2173
Mailing Address - Fax:
Practice Address - Street 1:2000 CLIFFMINE RD STE 300
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15275-1008
Practice Address - Country:US
Practice Address - Phone:412-926-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker