Provider Demographics
NPI:1467197327
Name:JAO, SUSAN LAURA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LAURA
Last Name:JAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5507
Mailing Address - Country:US
Mailing Address - Phone:631-553-7781
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program