Provider Demographics
NPI:1619722972
Name:JACKSON, SUSAN CAPRICE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAPRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WESTMINSTER DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-5064
Mailing Address - Country:US
Mailing Address - Phone:917-400-5108
Mailing Address - Fax:
Practice Address - Street 1:14 WESTMINSTER DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-5064
Practice Address - Country:US
Practice Address - Phone:917-400-5108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-20
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15059000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health