Provider Demographics
NPI:1578220547
Name:WILLETT-JACKSON, SAMANTHA (LCPAT, ATR)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILLETT-JACKSON
Suffix:
Gender:F
Credentials:LCPAT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 E JOPPA RD STE 400
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 E JOPPA RD STE 400
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5811
Practice Address - Country:US
Practice Address - Phone:410-449-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC353221700000X
23-568221700000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist