Healthcare Provider Details

I. General information

NPI: 1588520563
Provider Name (Legal Business Name): JACKSONS JUBILEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4317 HARFORD RD
BALTIMORE MD
21214-3118
US

IV. Provider business mailing address

4317 HARFORD RD
BALTIMORE MD
21214-3118
US

V. Phone/Fax

Practice location:
  • Phone: 443-653-9506
  • Fax: 410-275-0992
Mailing address:
  • Phone: 443-653-9506
  • Fax: 410-275-0992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA JACKSON
Title or Position: CEO
Credential:
Phone: 443-653-9506