Provider Demographics
NPI:1689914087
Name:JACKSON, SUSAN MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 MONTGOMERY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2280
Mailing Address - Country:US
Mailing Address - Phone:513-961-5558
Mailing Address - Fax:513-961-1912
Practice Address - Street 1:4805 MONTGOMERY RD STE 410
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-559-1222
Practice Address - Fax:513-559-1235
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP.13953363LA2200X
KY1135253363LA2200X
OHRN.259883-COA1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse