Provider Demographics
NPI:1750384616
Name:JACKSON, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
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 1:11279 PERRY HWY
Mailing Address - Street 2:STE 450
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8791 BARNES LAKE RD
Practice Address - Street 2:STE 202
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-3176
Practice Address - Country:US
Practice Address - Phone:724-864-6834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419732208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001908290004Medicaid
PA001908290004Medicaid