Healthcare Provider Details

I. General information

NPI: 1689914087
Provider Name (Legal Business Name): SUSAN MARIE JACKSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 MONTGOMERY RD STE 410
CINCINNATI OH
45212
US

IV. Provider business mailing address

4805 MONTGOMERY RD STE 150
CINCINNATI OH
45212-2280
US

V. Phone/Fax

Practice location:
  • Phone: 513-559-1222
  • Fax: 513-559-1235
Mailing address:
  • Phone: 513-961-5558
  • Fax: 513-961-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP.13953
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1135253
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.259883-COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: