Provider Demographics
NPI:1013796465
Name:JACKSON, SAMANTHA LOVIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LOVIE
Last Name:JACKSON
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 1:4663 BURLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-1211
Mailing Address - Country:US
Mailing Address - Phone:818-299-7648
Mailing Address - Fax:
Practice Address - Street 1:4663 BURLEIGH RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-1211
Practice Address - Country:US
Practice Address - Phone:818-299-7648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
376J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker