Provider Demographics
NPI:1992895700
Name:JACKSON, SUSAN K (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
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:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-0411
Mailing Address - Country:US
Mailing Address - Phone:919-989-5500
Mailing Address - Fax:
Practice Address - Street 1:521 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4407
Practice Address - Country:US
Practice Address - Phone:919-989-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRN074602163WP0808X
NCNP005000618363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005045Medicaid