Provider Demographics
NPI:1487427696
Name:STACKPOLE, SAMANTHA (DC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:STACKPOLE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-1633
Mailing Address - Country:US
Mailing Address - Phone:618-556-1062
Mailing Address - Fax:
Practice Address - Street 1:105 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-1633
Practice Address - Country:US
Practice Address - Phone:618-556-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038014047111N00000X
IL038.014047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor