Provider Demographics
NPI:1699889949
Name:JACKSON, SUSAN M (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8155
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13505
Mailing Address - Country:US
Mailing Address - Phone:315-736-0155
Mailing Address - Fax:315-732-0393
Practice Address - Street 1:1450 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3662
Practice Address - Country:US
Practice Address - Phone:315-624-9000
Practice Address - Fax:315-624-9003
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264949163W00000X
NY332294363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01866164Medicaid
NYJ400002719Medicare PIN