Samantha J Jackson, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

25126 Issued in MN

Practice address

2355 State St Ste 10
Salem, OR 97301-4541

Phone

(541) 577-1657

NPI assigned

Aug 18, 2021

Sex

Unspecified or another gender identity

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1629244800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1715126400000",
    "number": "1265108484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2355 STATE ST STE 10",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973014541",
            "telephone_number": "541-577-1657"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2355 STATE ST STE 10",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973014541",
            "telephone_number": "541-577-1657"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "202 N Cedar Ave Ste 1",
            "address_purpose": "LOCATION",
            "city": "Owatonna",
            "state": "MN",
            "postal_code": "550602306",
            "country_code": "US",
            "telephone_number": "541-577-6571",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SAMANTHA",
        "middle_name": "J",
        "credential": "LICSW",
        "sole_proprietor": "YES",
        "sex": "X",
        "enumeration_date": "2021-08-18",
        "last_updated": "2024-05-08",
        "certification_date": "2024-05-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "L14321",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "25126",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Karen Ann Jaccard
• Hamadi Jahi Jackson
• Judith Francine Jackson
• Julianne Ashley Jackson
• Kimberley Jennifer Jackson
• Stacy Ann Jackson, N/A
• Angelica Anna Jacob
• Alexa Jacoban
• Heather Evangeline Jacobs
• Jena Jacobs

• Clinical Social Worker in Salem, OR
• Providers in Salem, OR by specialty
• Clinical Social Worker in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 8, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.