Healthcare Provider Details

I. General information

NPI: 1053215459
Provider Name (Legal Business Name): SAMANTHA JO JACKSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S MAIN ST
CANTON IL
61520-2606
US

IV. Provider business mailing address

115 LINDEN ST
CANTON IL
61520-1114
US

V. Phone/Fax

Practice location:
  • Phone: 309-740-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.033548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: