Provider Demographics
NPI:1770659369
Name:JABLONSKI, SUSAN MARIE (FNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:JABLONSKI
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:PENDERGAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:55801 E 350 RD
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-6447
Mailing Address - Country:US
Mailing Address - Phone:918-353-7070
Mailing Address - Fax:
Practice Address - Street 1:9250 N 3RD ST STE 2007
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2404
Practice Address - Country:US
Practice Address - Phone:602-633-3780
Practice Address - Fax:602-633-3782
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10281363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1867632-01Medicaid
TX8J5982Medicare PIN