MEDICARE: JACQUELINE KRISTINE SAMUELSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A22893	NC

General Provider Information

NPI Number	:	1912846163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE KRISTINE SAMUELSON

Provider Business Mailing Address
First Line	:	61 CEDAR GROVE CT
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27527-7006
Country	:	US
Telephone Number	:	661-618-9101
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 VALENCIA DR STE 109
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6312
Country	:	US
Telephone Number	:	910-330-7559
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2026
Last Update Date	:	05/13/2026

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