Provider Demographics
NPI:1366689267
Name:JACKSON, SAMANTHA ROSE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:COSTNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:75 HWY 62-412
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513
Practice Address - Country:US
Practice Address - Phone:870-994-7060
Practice Address - Fax:870-994-7063
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR71659163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse