Healthcare Provider Details

I. General information

NPI: 1992895700
Provider Name (Legal Business Name): SUSAN K JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N BRIGHTLEAF BLVD
SMITHFIELD NC
27577-4407
US

IV. Provider business mailing address

PO BOX 411
SMITHFIELD NC
27577-0411
US

V. Phone/Fax

Practice location:
  • Phone: 919-989-5500
  • Fax:
Mailing address:
  • Phone: 919-989-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN074602
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP005000618
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: