Provider Demographics
NPI:1154339810
Name:JACKSON, CHRISTANN L (MD)
Entity type:Individual
Prefix:
First Name:CHRISTANN
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 LIBERTY AVENUE
Mailing Address - Street 2:SUITE GR59
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-3951
Mailing Address - Fax:412-578-1587
Practice Address - Street 1:4815 LIBERTY AVENUE
Practice Address - Street 2:SUITE GR59
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-3951
Practice Address - Fax:412-578-1587
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025329E207V00000X, 207SG0201X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001159026Medicaid
PA001159026Medicaid
105440Medicare PIN
PA105440K0EMedicare PIN