Provider Demographics
NPI:1972565950
Name:MARCINKO JACKSON, SUZANNE A (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:A
Last Name:MARCINKO JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:A
Other - Last Name:MARCINKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2649 SCHOENERSVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7326
Practice Address - Country:US
Practice Address - Phone:484-884-8146
Practice Address - Fax:484-884-8176
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331810363LF0000X
PATP004351B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPB4846Medicare PIN
S46242Medicare UPIN