Provider Demographics
NPI:1801191754
Name:JACKSON, SAMANTHA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5451
Mailing Address - Country:US
Mailing Address - Phone:336-349-5040
Mailing Address - Fax:336-369-5366
Practice Address - Street 1:1818 RICHARDSON DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5451
Practice Address - Country:US
Practice Address - Phone:336-349-5040
Practice Address - Fax:336-369-5366
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89163REMedicaid
NC2762653Medicare PIN