Provider Demographics
NPI:1881631059
Name:JACKSON, KATHRYN M
Entity type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:M
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 1:235 ALPHA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2940
Mailing Address - Country:US
Mailing Address - Phone:877-868-4827
Mailing Address - Fax:877-283-0663
Practice Address - Street 1:235 ALPHA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-2940
Practice Address - Country:US
Practice Address - Phone:877-868-4827
Practice Address - Fax:877-283-0663
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66815-600034363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC190482OtherMEDCOST
NC2630370OtherUHC
NC7003842Medicaid
NCQ69600Medicare UPIN
NC190482OtherMEDCOST