Healthcare Provider Details

I. General information

NPI: 1104806967
Provider Name (Legal Business Name): SAMANTHA JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W FOREST LN
HOBART OK
73651-1645
US

IV. Provider business mailing address

PO BOX 826
HOBART OK
73651-0826
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-2226
  • Fax: 580-726-8425
Mailing address:
  • Phone: 580-726-2226
  • Fax: 580-726-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19876
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: