Provider Demographics
NPI:1609683739
Name:JACKSON, RILEY THOMAS
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:THOMAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9936 W MOCCASIN TRL
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9309
Mailing Address - Country:US
Mailing Address - Phone:412-452-7406
Mailing Address - Fax:
Practice Address - Street 1:5231 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1768
Practice Address - Country:US
Practice Address - Phone:412-452-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator