Provider Demographics
NPI:1851038723
Name:JEFFERSON, SUSAN (APN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-0453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 MUNN AVE APT 1A
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-5712
Practice Address - Country:US
Practice Address - Phone:973-780-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ012904002084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry