Provider Demographics
NPI:1902380884
Name:JACOT, SAMANTHA ROSE (FNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:JACOT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:LIBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1941 JOHNSON AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4175
Mailing Address - Country:US
Mailing Address - Phone:805-786-4111
Mailing Address - Fax:805-543-6357
Practice Address - Street 1:1941 JOHNSON AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4175
Practice Address - Country:US
Practice Address - Phone:805-786-4111
Practice Address - Fax:805-543-6357
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily