Physician Compare National (NPI:1104806967)

HEALTHCARE PROVIDER: SAMANTHA JACKSON MD

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1104806967
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	7012002744
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20070926000847
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	JACKSON
	Individual professional last name
Provider First Name	SAMANTHA
	Individual professional first name
Provider Middle Name	L
	Individual professional middle name
Provider Gender	F
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE
	Individual professional's medical school
Graduation Year	1995
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	429 W ELM ST
	Group Practice or individual's line 1 address
Line 2 Street Address	ELK VIEW GENERAL HOSPITAL
	Group Practice or individual's line 2 address
City	HOBART
	Group Practice or individual's city
State	OK
	Group Practice or individual's state
Zip Code	736511615
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	370153
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	ELKVIEW GENERAL HOSPTIAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	371325
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	CORDELL MEMORIAL HOSPITAL
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	371330
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	MANGUM REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	370022
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
	Legal business name of hospital where individual professional provides service 4
Professional Accepts Medicare Assignment	Y