Provider Demographics
NPI:1477187292
Name:JEROME, SAMANTHA JOY
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOY
Last Name:JEROME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 GOOSEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:NC
Mailing Address - Zip Code:28762-8763
Mailing Address - Country:US
Mailing Address - Phone:828-216-9305
Mailing Address - Fax:
Practice Address - Street 1:5121 KINGDOM WAY STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6063
Practice Address - Country:US
Practice Address - Phone:828-216-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician