Provider Demographics
NPI:1245550433
Name:JACK, SAMARA JA'NEL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SAMARA
Middle Name:JA'NEL
Last Name:JACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SAMARA
Other - Middle Name:JA'NEL
Other - Last Name:RAMSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1705 E 19TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5410
Mailing Address - Country:US
Mailing Address - Phone:918-748-7585
Mailing Address - Fax:918-403-6352
Practice Address - Street 1:7858 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1857
Practice Address - Country:US
Practice Address - Phone:918-986-9200
Practice Address - Fax:918-986-9205
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant