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Individual

SUSAN M JACKSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
FNP

Contact information

Practice address
1450 CHAMPLIN AVE, UTICA, NY 13502-3662
(315) 624-9000
(315) 624-9003
Mailing address
PO BOX 8155, UTICA, NY 13505
(315) 736-0155
(315) 732-0393

Taxonomy

Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
264949
NY
363L00000X
Nurse Practitioner
Primary
332294
NY

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
01866164
NY
Enumeration date
08/17/2006
Last updated
03/09/2020
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