Provider Demographics
NPI:1366007098
Name:JACKSON, SAMIA (BS)
Entity Type:Individual
Prefix:
First Name:SAMIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W BEAVER ST STE 205
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1416
Mailing Address - Country:US
Mailing Address - Phone:904-712-3540
Mailing Address - Fax:904-775-3570
Practice Address - Street 1:1225 W BEAVER ST STE 205
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1416
Practice Address - Country:US
Practice Address - Phone:904-712-3540
Practice Address - Fax:904-775-3570
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor