Provider Demographics
NPI:1467454652
Name:SAMSON, JACQUELINE ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANNE
Last Name:SAMSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:ANNE
Other - Last Name:SAMSON-JAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1041
Mailing Address - Country:US
Mailing Address - Phone:617-855-3348
Mailing Address - Fax:617-855-2936
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1041
Practice Address - Country:US
Practice Address - Phone:617-855-3348
Practice Address - Fax:617-855-2936
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4522103TB0200X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA01950OtherVALUE OPTIONS
MAW05381OtherBLUE CROSS BLUE SHIELD
MA001458OtherHARVARD PILGRIM HEALTH CA
MA1858807OtherMASSHEALTH
MA001458OtherHARVARD PILGRIM HEALTH CA