Provider Demographics
NPI:1831915388
Name:JACKSON, LAUREN SAMANTHA
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:SAMANTHA
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 1:637 WYNDSTAR CIR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-4439
Mailing Address - Country:US
Mailing Address - Phone:443-625-8972
Mailing Address - Fax:
Practice Address - Street 1:400 E PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-3116
Practice Address - Country:US
Practice Address - Phone:410-883-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician