Provider Demographics
NPI:1588095988
Name:JONES, SAMANTHA (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:WADFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:125 BACKHALL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHEN
Mailing Address - State:SC
Mailing Address - Zip Code:29479-3593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5832
Practice Address - Country:US
Practice Address - Phone:843-852-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18613363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid