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General NPI Number Information
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NPI Number | 1609438225
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Entity Type | Individual
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Provider Name | SAMANTHA LACHELLE JACKSON LCPC
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Gender | Female
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Dates
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Enumeration Date | 07/03/2019
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Last Update Date | 06/05/2023
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Provider Practice Location Address
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Address Line | 4317 HARFORD RD
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City | BALTIMORE
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State | MD
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Zip | 21214-3118
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Country | US
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Telephone | 443-708-7510
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Fax | 410-275-0992
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Provider Business Mailing Address
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Address Line | 4317 HARFORD RD
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City | BALTIMORE
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State | MD
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Zip | 21214-3118
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Country | US
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Telephone | 410-275-0994
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Fax | 410-275-0992
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LGP9650
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC11555
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License Number State | MD
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