Provider Demographics
NPI:1275973646
Name:SAMANTHA JACKSON MD PLLC
Entity Type:Organization
Organization Name:SAMANTHA JACKSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-726-2226
Mailing Address - Street 1:415 W FOREST LN
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651-1645
Mailing Address - Country:US
Mailing Address - Phone:580-726-2226
Mailing Address - Fax:580-726-8425
Practice Address - Street 1:415 W FOREST LN
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-1645
Practice Address - Country:US
Practice Address - Phone:580-726-2226
Practice Address - Fax:580-726-8425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMANTHA L JACKSON MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-01
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200491840AMedicaid
OK200491840AMedicaid