Provider Demographics
NPI:1700351442
Name:JACKATEY, SUZIE FATOU (NP)
Entity Type:Individual
Prefix:MS
First Name:SUZIE
Middle Name:FATOU
Last Name:JACKATEY
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 1:1003 KINGS TREE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1918
Mailing Address - Country:US
Mailing Address - Phone:857-999-6122
Mailing Address - Fax:
Practice Address - Street 1:14502 GREENVIEW DR STE 500
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-4245
Practice Address - Country:US
Practice Address - Phone:857-999-6122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017987363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily