Provider Demographics
NPI:1689136384
Name:JACKSON, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10602 SHIMMER BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-3304
Mailing Address - Country:US
Mailing Address - Phone:281-939-6652
Mailing Address - Fax:
Practice Address - Street 1:10602 SHIMMER BLUFF LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-3304
Practice Address - Country:US
Practice Address - Phone:281-939-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist