Healthcare Provider Details

I. General information

NPI: 1205182177
Provider Name (Legal Business Name): SAMANTHA RAE STAPLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 E MAIN ST SUITE16
JACKSON OH
45640-2100
US

IV. Provider business mailing address

731 E MAIN ST SUITE16
JACKSON OH
45640-2100
US

V. Phone/Fax

Practice location:
  • Phone: 740-286-5245
  • Fax: 740-286-7642
Mailing address:
  • Phone: 740-286-5245
  • Fax: 740-286-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS0900850
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: