Provider Demographics
NPI:1790803229
Name:JACKSLAND, SUSAN J (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:JACKSLAND
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3417 SLATE STREET
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7593
Mailing Address - Country:US
Mailing Address - Phone:407-242-7070
Mailing Address - Fax:
Practice Address - Street 1:1990 NEW HAVEN AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-773-1737
Practice Address - Fax:321-773-1737
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT0004353174400000X
FLOT4353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist