Provider Demographics
NPI:1609438225
Name:JACKSON, SAMANTHA LACHELLE (LCPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LACHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-3118
Mailing Address - Country:US
Mailing Address - Phone:410-275-0994
Mailing Address - Fax:410-275-0992
Practice Address - Street 1:4317 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3118
Practice Address - Country:US
Practice Address - Phone:443-708-7510
Practice Address - Fax:410-275-0992
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9650101YP2500X
MDLC11555101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD210292700Medicaid