Provider Demographics
NPI:1740851070
Name:JEWETT, SAMANTHA LEE (LPC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:JEWETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16450 RUSS RD
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-7097
Mailing Address - Country:US
Mailing Address - Phone:806-335-0658
Mailing Address - Fax:
Practice Address - Street 1:16450 RUSS RD
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-7097
Practice Address - Country:US
Practice Address - Phone:806-335-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional