Provider Demographics
NPI:1215121835
Name:JACKSON, TRACEY (PA-C)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:SEYLAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1307 FEDERAL ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4769
Mailing Address - Country:US
Mailing Address - Phone:877-660-6777
Mailing Address - Fax:412-359-8055
Practice Address - Street 1:320 E NORTH AVE FL 1
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-8820
Practice Address - Fax:412-330-5411
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053116363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA524083PNLMedicare PIN