Provider Demographics
NPI:1891543476
Name:JACKSON, JONATHAN MATTHEW (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2984 SIDNEY ST APT 329
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-5148
Mailing Address - Country:US
Mailing Address - Phone:301-807-3949
Mailing Address - Fax:
Practice Address - Street 1:3501 TERRACE ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2523
Practice Address - Country:US
Practice Address - Phone:412-648-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0435621223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics