Provider Demographics
NPI:1548926306
Name:JACKSON, SUSANNAH ROSE (PA)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVENUE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-428-3175
Mailing Address - Fax:740-283-7807
Practice Address - Street 1:4000 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2364
Practice Address - Country:US
Practice Address - Phone:740-264-8039
Practice Address - Fax:740-264-8049
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008544RX363A00000X
PAMA064330363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0035572Medicaid