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SAMUEL WESLEY JACKSON MD
NPI 1114480001
Psychiatry & Neurology - Psychiatry in Chicago, IL

Active since April 09, 2019PECOS EnrolledAccepts Medicare Assignment
5215 N CALIFORNIA AVE FL 7, CHICAGO, IL 60625(718) 270-8867 Get Directions Write a Review

NPPES record last updated: November 26, 2024. Verified against the NPPES registry weekly; last sync: October 25, 2026.

About Samuel Wesley Jackson Md NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SAMUEL WESLEY JACKSON MD (NPI 1114480001) is an individual psychiatry provider in Chicago, Illinois, licensed in Illinois (169934) and active in the NPI registry since April 2019. He is enrolled in Medicare PECOS and is a graduate of Other (2019).

NPPES Registry Identity

NPI1114480001
Entity TypeIndividualMale
Primary Taxonomy2084P0800X
Provider Legal NameSAMUEL WESLEY JACKSONCredential: MD
Location Address5215 N CALIFORNIA AVE FL 7Chicago, IL 60625-7014
Mailing Address5215 N California Ave Fl 7Chicago, IL 60625-7014
Phone(718) 270-8867
Sole ProprietorNo
Medical School CMSOtherGraduated 2019
Enumeration DateApril 9, 2019
Last NPPES UpdateNovember 26, 2024
NPPES CertifiedNovember 26, 2024
✔ NPI 1114480001 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPsychiatry & Neurology · PsychiatryAllopathic & Osteopathic Physicians
Taxonomy Code2084P0800X
License✔ Licensed in IL · 169934
Definition
A Psychiatrist specializes in the prevention, diagnosis, and treatment of mental disorders, emotional disorders, psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, sexual and gender identity disorders and adjustment disorders. Biologic, psychological, and social components of illnesses are explored and understood in treatment of the whole person. Tools used may include diagnostic laboratory tests, prescribed medications, evaluation and treatment of psychological and interpersonal problems with individuals and families, and intervention for coping with stress, crises, and other problems.
5215 N CALIFORNIA AVE FL 7, Chicago, IL 60625
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Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Ambetter Health, Ambetter Health of Delaware.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Samuel Wesley Jackson Md is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID1759821002
PECOS Enrollment IDI20250103002976
Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Medicare Billing Reassignment

Medicare enrollment records show Samuel Jackson reassigns Medicare billing to 1 organization. The organization bills Medicare for the services this provider delivers there.

Erie Family Health Center Inc
Same address
Federally Qualified Health Center (FQHC)
5215 N CALIFORNIA AVE STE F700
Chicago, IL 60625
  • Reassigned Medicare billing, Illinois enrollment
  • 383 clinicians in this Medicare group
NPI 1396181590 (312) 666-3494

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 60625 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient
$183.39 typical visit price
range $60.08 – $183.39
Typical copayment $45.84 (range $15.02 – $45.84)
Most-billed visit code 99205
Established Patient
$74.80 typical visit price
range $18.97 – $148.12
Typical copayment $18.70 (range $4.74 – $37.03)
Most-billed visit code 99213
Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES 19

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

SARAH ANNE LAMBETH MD, MS
Obstetrics & Gynecology
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
AMANDA BUCK DO
Obstetrics & Gynecology
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
YESENIA CEJA PNP
Nurse Practitioner (Pediatrics)
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
JOSHUA LEVINE
Internal Medicine (Endocrinology, Diabetes & Metabolism)
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
ANISHA GILL FNP-C
Nurse Practitioner (Family)
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
JOHNNY PEREZ
Nurse Practitioner (Family)
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
LABORATORY CORPORATION OF AMERICA
Clinical Medical Laboratory
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494
DR. MIRANDA ANNE HART M.D.
Internal Medicine
5215 N CALIFORNIA AVE FL 7
CHICAGO, IL 60625
Cook County (312) 666-3494

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Samuel Jackson's NPI number?

The NPI number for Samuel Jackson is 1114480001. It was assigned to this individual provider in the NPPES registry on April 9, 2019.

Where is Samuel Jackson located?

Samuel Jackson practices at 5215 N California Ave Fl 7, Chicago, IL 60625. The listed phone number is (718) 270-8867.

What is Samuel Jackson's specialty?

The primary specialty registered for this NPI is Psychiatry & Neurology, specializing in Psychiatry, with taxonomy code 2084P0800X.

Is Samuel Jackson enrolled in Medicare?

Yes. Samuel Jackson is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.

Which organization bills Medicare for Samuel Jackson's services?

According to the CMS Revalidation Reassignment List (October 2026 release), Samuel Jackson reassigns Medicare benefits to Erie Family Health Center Inc (Chicago, IL). The reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Samuel Jackson's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.

What insurance does Samuel Jackson accept?

Health plans from Ambetter Health and Ambetter Health of Delaware list Samuel Jackson as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

When was this NPI record last updated?

The NPPES record for Samuel Jackson was last updated on November 26, 2024. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 23 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.