Provider Demographics
NPI:1962877431
Name:JACKSON, SUSAN ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 RIDINGS MANOR PL
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-4914
Mailing Address - Country:US
Mailing Address - Phone:703-307-1810
Mailing Address - Fax:
Practice Address - Street 1:1365 BEVERLY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3624
Practice Address - Country:US
Practice Address - Phone:703-790-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily