Healthcare Provider Details

I. General information

NPI: 1477463610
Provider Name (Legal Business Name): SAMANTHA JERNIGAN MT, NMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 NORTHSIDE DR
VALDOSTA GA
31602-1801
US

IV. Provider business mailing address

4562 AMELIA CIR
HAHIRA GA
31632-2640
US

V. Phone/Fax

Practice location:
  • Phone: 229-375-2836
  • Fax:
Mailing address:
  • Phone: 229-375-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT013045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: