Provider Demographics
NPI:1316327265
Name:JACKLINE, LARISSA ANN (CRNP)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:JACKLINE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MARY ST
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-2054
Mailing Address - Country:US
Mailing Address - Phone:412-488-5705
Mailing Address - Fax:412-488-5206
Practice Address - Street 1:2000 MARY ST
Practice Address - Street 2:SUITE 2500
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-2054
Practice Address - Country:US
Practice Address - Phone:412-488-5705
Practice Address - Fax:412-488-5206
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014869363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily