Provider Demographics
NPI:1649557208
Name:JACKSON, SUSAN ELAINE (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LEACH RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9732
Mailing Address - Country:US
Mailing Address - Phone:315-946-6075
Mailing Address - Fax:
Practice Address - Street 1:12 LEACH RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9732
Practice Address - Country:US
Practice Address - Phone:315-946-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015280363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical