Provider Demographics
NPI:1619370442
Name:SAMUELS-JACKSOM, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:SAMUELS-JACKSOM
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 1:26525 AMHEARST CIR
Mailing Address - Street 2:110
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-8506
Mailing Address - Country:US
Mailing Address - Phone:862-202-3910
Mailing Address - Fax:
Practice Address - Street 1:26525 AMHEARST CIR
Practice Address - Street 2:110
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-8506
Practice Address - Country:US
Practice Address - Phone:862-202-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02165171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist