Provider Demographics
NPI:1144718172
Name:C MICHAELA JACKS LLC
Entity type:Organization
Organization Name:C MICHAELA JACKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:412-213-8425
Mailing Address - Street 1:1789 S BRADDOCK AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15218-1871
Mailing Address - Country:US
Mailing Address - Phone:412-213-8425
Mailing Address - Fax:
Practice Address - Street 1:1789 S BRADDOCK AVE STE 350
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15218-1871
Practice Address - Country:US
Practice Address - Phone:412-213-8425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000999261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)