Provider Demographics
NPI:1033750773
Name:JEFFERSON, SAMANTHA BROOKE (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:BROOKE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-1895
Mailing Address - Country:US
Mailing Address - Phone:410-444-2100
Mailing Address - Fax:410-426-1140
Practice Address - Street 1:5807 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1895
Practice Address - Country:US
Practice Address - Phone:410-444-2100
Practice Address - Fax:410-426-1140
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD934101YA0400X
MD1733711041C0700X, 1041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000000Medicaid