Healthcare Provider Details

I. General information

NPI: 1912846163
Provider Name (Legal Business Name): JACQUELINE KRISTINE SAMUELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VALENCIA DR STE 109
JACKSONVILLE NC
28546-6312
US

IV. Provider business mailing address

61 CEDAR GROVE CT
CLAYTON NC
27527-7006
US

V. Phone/Fax

Practice location:
  • Phone: 910-330-7559
  • Fax:
Mailing address:
  • Phone: 661-618-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22893
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: