Provider Demographics
NPI:1699951368
Name:JACKSON, SUSAN ELIZABETH (EDD,APN-BC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:EDD,APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAIR AVE
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2313
Mailing Address - Country:US
Mailing Address - Phone:973-256-1732
Mailing Address - Fax:973-256-5497
Practice Address - Street 1:20 MAIR AVE
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2313
Practice Address - Country:US
Practice Address - Phone:973-256-1732
Practice Address - Fax:973-256-5497
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00146900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health