Healthcare Provider Details

I. General information

NPI: 1467987834
Provider Name (Legal Business Name): SUSAN L JAREK PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SUSAN L GILMARTIN

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11815 FOUNTAIN WAY STE 300
NEWPORT NEWS VA
23606-4448
US

IV. Provider business mailing address

PO BOX 6865
WILLIAMSBURG VA
23188-5231
US

V. Phone/Fax

Practice location:
  • Phone: 757-603-3986
  • Fax:
Mailing address:
  • Phone: 757-310-8167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number061597-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024175618
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number061597-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: