Provider Demographics
NPI:1124110911
Name:JACKSON-WALKER, SUSAN M (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:JACKSON-WALKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NEMOURS CHILDRENS CLINIC
Mailing Address - Street 2:P.O. BOX 404112
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:A.I. DUPONT HOSPITAL FOR CHILDREN
Practice Address - Street 2:1600 ROCKLAND ROAD
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEB10000648103TC2200X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5119049Medicaid
NJ8919704Medicaid
PA1913085Medicaid
P71213Medicare UPIN
010527T34Medicare PIN