MEDICARE: SAMIA JACKSON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN11002840	FL
2	363LP2300X	Primary Care Nurse Practitioner	APRN11002840	FL

General Provider Information

NPI Number	:	1013565811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMIA JACKSON APRN

Provider Business Mailing Address
First Line	:	1633 RACE TRACK RD STE 101
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-3237
Country	:	US
Telephone Number	:	904-230-6988
Fax Number	:	904-342-4028

Provider Business Practice Location Address
First Line	:	14444 BEACH BLVD STE 28
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-2080
Country	:	US
Telephone Number	:	904-367-2277
Fax Number	:	904-421-3788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	02/13/2026

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