Provider Demographics
NPI:1780749671
Name:JACKSON, SUSAN MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25054 SR 11
Mailing Address - Street 2:
Mailing Address - City:HALLSTEAD
Mailing Address - State:PA
Mailing Address - Zip Code:18822
Mailing Address - Country:US
Mailing Address - Phone:570-879-6870
Mailing Address - Fax:570-879-6861
Practice Address - Street 1:25066 SR 11
Practice Address - Street 2:
Practice Address - City:HALLSTEAD
Practice Address - State:PA
Practice Address - Zip Code:18822
Practice Address - Country:US
Practice Address - Phone:570-879-5249
Practice Address - Fax:570-879-2418
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000163890207Q00000X
NY244722207Q00000X
PAOS015552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02903533Medicaid
NYRB5803Medicare PIN