Healthcare Provider Details

I. General information

NPI: 1912849860
Provider Name (Legal Business Name): SAMANTHA JACOBSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8652 E EASTRIDGE RD STE 201
PRESCOTT VALLEY AZ
86314-9464
US

IV. Provider business mailing address

3256 W HUNTINGTON DR
PHOENIX AZ
85041-4339
US

V. Phone/Fax

Practice location:
  • Phone: 928-830-2410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number005707
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number005707
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number005507
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: