Healthcare Provider Details

I. General information

NPI: 1841543188
Provider Name (Legal Business Name): ALISSA CARA JECKLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5549 HIGHWAY K
BRIGHTON MO
65617-7256
US

IV. Provider business mailing address

5549 HWY K PO BOX 617
BRIGHTON MO
65617-0617
US

V. Phone/Fax

Practice location:
  • Phone: 417-376-2238
  • Fax:
Mailing address:
  • Phone: 417-376-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2012025060
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: