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General NPI Number Information
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NPI Number | 1184362600
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Entity Type | Individual
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Provider Name | SAMALA JACKSON CRNP
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Gender | Female
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Dates
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Enumeration Date | 05/24/2022
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Last Update Date | 10/24/2025
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Provider Practice Location Address
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Address Line | 1055 WESTLAKES DR STE 3152
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City | BERWYN
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State | PA
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Zip | 19312-2410
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Country | US
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Telephone | 215-346-6050
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Fax | 215-220-3562
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Provider Business Mailing Address
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Address Line | PO BOX 40412
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City | BELFAST
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State | ME
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Zip | 04915-1255
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Country | US
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Telephone | 248-824-6500
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Fax | 855-618-6655
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | SP018935
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License Number State | PA
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