Provider Demographics
NPI:1427150242
Name:JACKSON, SUSANNE SOCHA
Entity type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:SOCHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W TRINITY AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1826
Mailing Address - Country:US
Mailing Address - Phone:919-688-3079
Mailing Address - Fax:919-688-8049
Practice Address - Street 1:2100 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-688-3079
Practice Address - Fax:919-688-8049
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201136363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2592742Medicare PIN