Healthcare Provider Details

I. General information

NPI: 1104757426
Provider Name (Legal Business Name): JESSICA SAMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 CAPE HORN RD
RED LION PA
17356-9057
US

IV. Provider business mailing address

2555 CAPE HORN RD
RED LION PA
17356-9057
US

V. Phone/Fax

Practice location:
  • Phone: 717-600-0900
  • Fax: 717-600-0910
Mailing address:
  • Phone: 717-600-0900
  • Fax: 717-600-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBH007068
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: