Provider Demographics
NPI:1780024349
Name:JAKAUB, SUSAN MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:JAKAUB
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 BARNARD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-2171
Mailing Address - Country:US
Mailing Address - Phone:315-406-6774
Mailing Address - Fax:
Practice Address - Street 1:115 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1227
Practice Address - Country:US
Practice Address - Phone:315-593-2158
Practice Address - Fax:315-252-3869
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI057731-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist