Provider Demographics
NPI:1619457926
Name:JACKSON, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:884 MAPLE SHADE RD
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:16319-3318
Mailing Address - Country:US
Mailing Address - Phone:412-512-0798
Mailing Address - Fax:
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2975
Practice Address - Country:US
Practice Address - Phone:412-512-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant