Provider Demographics
NPI:1982857090
Name:JENNER, SUSAN MARJORIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARJORIE
Last Name:JENNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STICKLEY DR
Mailing Address - Street 2:PO BOX 480
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2484
Mailing Address - Country:US
Mailing Address - Phone:315-682-5500
Mailing Address - Fax:315-682-8669
Practice Address - Street 1:1 STICKLEY DR
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2484
Practice Address - Country:US
Practice Address - Phone:315-682-5500
Practice Address - Fax:315-682-8669
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301000-1363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health