Provider Demographics
NPI:1659105195
Name:JACKSON, SUYAPA MARIEL (NP)
Entity type:Individual
Prefix:
First Name:SUYAPA
Middle Name:MARIEL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 PADOVA AVE
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5386
Mailing Address - Country:US
Mailing Address - Phone:601-209-9031
Mailing Address - Fax:
Practice Address - Street 1:1523 PADOVA AVE
Practice Address - Street 2:
Practice Address - City:TONTITOWN
Practice Address - State:AR
Practice Address - Zip Code:72762-5386
Practice Address - Country:US
Practice Address - Phone:601-209-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906658363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology