NPIMap

Individual provider Active NPI

Susan M Jackson, FNP

  • Nurse Practitioner
  • Utica, NY
National Provider Identifier
1699889949
Registry record updated Mar 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
License
332294 Issued in NY
Practice address
1450 Champlin Ave
Utica, NY 13502-3662
Phone
(315) 624-9000
Fax
(315) 624-9003
NPI assigned
Aug 17, 2006
Last updated
Mar 9, 2020By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X 332294 NY Primary
Registered Nurse 163W00000X 264949 NY

Addresses

Primary practice location

1450 Champlin Ave
Utica, NY 13502-3662

Mailing address

PO Box 8155
Utica, NY 13505
Phone (315) 736-0155

Other practice location 1

1703 Genesee St
Utica, NY 13501
Phone (315) 736-0155

Other practice location 2

2305 Genesee St
Utica, NY 13501-6107
Phone (315) 624-9000

Other identifiers 1

IdentifierTypeStateIssuer
01866164MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20090415000473 NY Practitioner - Nurse Practitioner 0547317224 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 1998
Medicare assignment
May accept Medicare assignment
Group practices
Primary Care Metabolic Disorders Medical Practice PLLCGroup PAC ID 5799116737, 2 clinicians

Practice addresses (Care Compare)

1450 Champlin Ave
Suite 1
Utica, NY 13502-3643
Phone (315) 624-2900

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
264949NYMDRegistered Nurse
332294NYMDAnesthesiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Sleep Disorders Lab of Central New York, LLC CurrentSince Mar 1, 2020 Accepting new patients
Primary Care Metabolic Disorders Medical Practice, PLLC CurrentSince Mar 1, 2020 Accepting new patients
Nursing Home Services Inc Past Accepting new patients
Mohawk Valley Urology PC Past Accepting new patients

Locations

111 E Chestnut St
Ste 2
Rome, NY 13440
Phone (315) 624-9004

7845 Rome Westernville Rd
Rome, NY 13440
Phone (315) 337-2500

1450 Champlin Ave
Utica, NY 13502
Phone (315) 624-8127

1450 Champlin Ave
Ste 1
Utica, NY 13502
Phone (315) 624-2900

2305 Genesee St
Utica, NY 13501
Phone (315) 724-8888

Interoperability endpoints

  • Direct secure messaging: susanjacksonfnp@mvmp.medentdirect.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 13

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155772800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1583712000000",
    "number": "1699889949",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 8155",
            "city": "UTICA",
            "state": "NY",
            "postal_code": "13505",
            "telephone_number": "315-736-0155",
            "fax_number": "315-732-0393"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1450 CHAMPLIN AVE",
            "city": "UTICA",
            "state": "NY",
            "postal_code": "135023662",
            "telephone_number": "315-624-9000",
            "fax_number": "315-624-9003"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1703 Genesee St",
            "address_purpose": "LOCATION",
            "city": "Utica",
            "state": "NY",
            "postal_code": "13501",
            "country_code": "US",
            "telephone_number": "315-736-0155",
            "fax_number": "315-732-0393",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2305 Genesee St",
            "address_purpose": "LOCATION",
            "city": "Utica",
            "state": "NY",
            "postal_code": "135016107",
            "country_code": "US",
            "telephone_number": "315-624-9000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SUSAN",
        "middle_name": "M",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-17",
        "last_updated": "2020-03-09",
        "certification_date": "2020-03-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NY",
            "license": "332294",
            "primary": true
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NY",
            "license": "264949",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01866164",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Utica, NY

Sources for this page

Verify at the official NPI Registry.